[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4822 Introduced in House (IH)]
<DOC>
118th CONGRESS
1st Session
H. R. 4822
To improve price transparency with respect to certain health care
services, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 24, 2023
Mr. Smith of Missouri introduced the following bill; which was referred
to the Committee on Energy and Commerce, and in addition to the
Committees on Ways and Means, Education and the Workforce, and the
Budget, for a period to be subsequently determined by the Speaker, in
each case for consideration of such provisions as fall within the
jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To improve price transparency with respect to certain health care
services, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Health Care Price
Transparency Act of 2023''.
(b) Table of Contents.--The table of contents for this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--HEALTH CARE PRICE TRANSPARENCY FOR PATIENTS
Sec. 101. Requiring certain facilities under the Medicare program to
disclose certain information relating to
charges and prices.
Sec. 102. Promoting group health plan price transparency.
Sec. 103. Oversight of pharmacy benefits manager services.
Sec. 104. Reports on health care transparency tools and data
requirements.
Sec. 105. Report on integration in Medicare.
TITLE II--FAIR PRICES FOR PATIENTS
Sec. 201. Limitation on cost sharing to net price amount under Medicare
part D.
Sec. 202. Requiring a separate identification number and an attestation
for each off-campus outpatient department
of a provider.
Sec. 203. Parity in Medicare payments for hospital outpatient
department services furnished off-campus.
TITLE III--PATIENT-FOCUSED INVESTMENTS
Sec. 301. Establishing requirements with respect to the use of prior
authorization under Medicare Advantage
plans.
Sec. 302. Extension of certain direct spending reductions.
TITLE I--HEALTH CARE PRICE TRANSPARENCY FOR PATIENTS
SEC. 101. REQUIRING CERTAIN FACILITIES UNDER THE MEDICARE PROGRAM TO
DISCLOSE CERTAIN INFORMATION RELATING TO CHARGES AND
PRICES.
(a) In General.--Part E of title XVIII of the Social Security Act
(42 U.S.C. 1395x et seq.) is amended by adding at the end the following
new section:
``SEC. 1899C. HEALTH CARE PROVIDER PRICE TRANSPARENCY.
``(a) Hospital Price Transparency.--
``(1) In general.--Beginning January 1, 2026, each
specified hospital (as defined in paragraph (6)) that receives
payment under this title for furnishing items and services
shall comply with the price transparency requirement described
in paragraph (2).
``(2) Requirement described.--
``(A) In general.--For purposes of paragraph (1),
the price transparency requirement described in this
paragraph is, with respect to a specified hospital,
that such hospital, in accordance with a method and
format established by the Secretary under subparagraph
(C), compile and make public (without subscription and
free of charge) for each year--
``(i) one or more lists, in a format
specified by the Secretary (which may be a
machine-readable format), of the hospital's
standard charges (including the information
described in subparagraph (B)) for each item
and service furnished by such hospital; and
``(ii) information in a consumer-friendly
format (as specified by the Secretary)--
``(I) on the hospital's prices
(including the information described in
subparagraph (B)) for as many of the
Centers for Medicare & Medicaid
Services-specified shoppable services
that are furnished by the hospital, and
as many additional hospital-selected
shoppable services (or all such
additional services, if such hospital
furnishes fewer than 300 shoppable
services) as may be necessary for a
combined total of at least 300
shoppable services; and
``(II) that includes, with respect
to each Centers for Medicare & Medicaid
Services-specified shoppable service
that is not furnished by the hospital,
an indication that such service is not
so furnished.
``(B) Information described.--For purposes of
subparagraph (A), the information described in this
subparagraph is, with respect to standard charges and
prices (as applicable) made public by a specified
hospital, the following:
``(i) A description of each item or
service, accompanied by, as applicable, the
Healthcare Common Procedure Coding System code,
the diagnosis-related group, the national drug
code, or other identifier used or approved by
the Centers for Medicare & Medicaid Services.
``(ii) The gross charge, expressed as a
dollar amount, for each such item or service,
when provided in, as applicable, the inpatient
setting and outpatient department setting.
``(iii) The discounted cash price,
expressed as a dollar amount, for each such
item or service when provided in, as
applicable, the inpatient setting and
outpatient department setting (or, in the case
no discounted cash price is available for an
item or service, the median price charged by
the hospital for such item or service when
provided in such settings for the previous
three years, expressed as a dollar amount).
``(iv) Any other information the Secretary
may require for purposes of promoting public
awareness of specified hospital standard
charges or prices in advance of receiving an
item or service from such a hospital, except
information that is duplicative of any other
reporting requirement under this section. Such
information may include any current payer-
specific negotiated charges, clearly associated
with the name of the third party payer and plan
and expressed as a dollar amount, that apply to
each such item or service when provided in, as
applicable, the inpatient setting and
outpatient department setting.
``(C) Method and format.--Not later than January 1,
2026, the Secretary shall establish one or more methods
and formats for specified facilities to use in
compiling and making public standard charges and prices
(as applicable) pursuant to subparagraph (A). Any such
method and format--
``(i) may be similar to any template made
available by the Centers for Medicare &
Medicaid Services as of the date of the
enactment of this subparagraph;
``(ii) shall meet such standards as
determined appropriate by the Secretary in
order to ensure the accessibility and usability
of such charges and prices; and
``(iii) shall be updated as determined
appropriate by the Secretary, in consultation
with stakeholders.
``(3) Deemed compliance with shoppable services requirement
for hospitals with a price estimator tool.--
``(A) In general.--With respect to each year until
the effective date of regulations implementing the
provisions of sections 2799A-1(f) and 2799B-6 of the
Public Health Service Act (relating to advanced
explanations of benefits), including regulations on
establishing data transfer standards to effectuate such
provisions, a specified hospital shall be deemed to
have complied with the requirement described in
paragraph (2)(A)(ii)(I) (relating to shoppable
services) if such hospital maintains a price estimator
tool described in subparagraph (B).
``(B) Price estimator tool described.--For purposes
of subparagraph (A), the price estimator tool described
in this subparagraph is, with respect to a specified
hospital, a tool that meets the following requirements:
``(i) Such tool allows an individual to
immediately obtain a price estimate (taking
into account whether such individual is covered
under any plan, coverage, or program described
in clause (iv)(III)) and the discounted cash
price charged by a specified hospital, for each
Centers for Medicare & Medicaid Services-
specified shoppable service that is furnished
by such hospital, and for each additional
shoppable service as such hospital may select,
such that price estimates are available through
such tool for at least 300 shoppable services
(or for all such services, if such hospital
furnishes fewer than 300 shoppable services).
``(ii) Such tool allows an individual to
obtain such an estimate by billing code and by
service description.
``(iii) Such tool is prominently displayed
on the public internet website of such
hospital.
``(iv) Such tool does not require an
individual seeking such an estimate to create
an account or otherwise input personal
information, except that such tool may require
that such individual provide information
specified by the Secretary, which may include
the following:
``(I) The name of such individual.
``(II) The date of birth of such
individual.
``(III) In the case such individual
is covered under a group health plan,
group or individual health insurance
coverage, a Federal health care
program, or the program established
under chapter 89 of title 5, United
States Code, an identifying number
assigned by such plan, coverage, or
program to such individual.
``(IV) In the case of an individual
described in subclause (III), an
indication as to whether such
individual is the primary insured
individual under such plan, coverage,
or program (and, if such individual is
not the primary insured individual, a
description of the individual's
relationship to such primary insured
individual).
``(V) Any other information
specified by the Secretary.
``(v) Such tool contains a statement
confirming the accuracy and completeness of
information presented through such tool as of
the date such request is made.
``(vi) Such tool meets any other
requirement specified by the Secretary.
``(4) Monitoring compliance.--The Secretary shall, through
notice and comment rulemaking and in consultation with the
Inspector General of the Department of Health and Human
Services, establish a process to monitor compliance with this
subsection. Such process shall ensure that each specified
hospital's compliance with this subsection is reviewed not less
frequently than once every 3 years.
``(5) Enforcement.--
``(A) In general.--In the case of a specified
hospital that fails to comply with the requirements of
this subsection--
``(i) the Secretary shall notify such
hospital of such failure not later than 30 days
after the date on which the Secretary
determines such failure exists; and
``(ii) upon request of the Secretary, the
hospital shall submit to the Secretary, not
later than 45 days after the date of such
request, a corrective action plan to comply
with such requirements.
``(B) Civil monetary penalty.--
``(i) In general.--In addition to any other
enforcement actions or penalties that may apply
under another provision of law, a specified
hospital that has received a notification under
subparagraph (A)(i) and fails to comply with
the requirements of this subsection by the date
that is 90 days after such notification (or, in
the case of such a hospital that has submitted
a corrective action plan described in
subparagraph (A)(ii) in response to a request
so described, by the date that is 90 days after
the Secretary identifies the failure of such
hospital to satisfactorily complete such
corrective action plan) shall be subject to a
civil monetary penalty of an amount specified
by the Secretary for each subsequent day during
which such failure is ongoing. Such amount
shall not exceed--
``(I) in the case of a specified
hospital that is a hospital or critical
access hospital with 30 or fewer beds,
$300 per day; and
``(II) in the case of any specified
hospital and except as provided in
clause (iii), $2,000,000 for a 1-year
period.
``(ii) Increase authority.--In applying
this subparagraph with respect to violations
occurring in 2027 or a subsequent year, the
Secretary may through notice and comment
rulemaking increase--
``(I) the limitation on the per day
amount of any penalty applicable to a
specified hospital that is a hospital
or critical access hospital with 30 or
fewer beds under clause (i)(I);
``(II) the limitation on the amount
of any penalty applicable for a 1-year
period under clause (i)(II); and
``(III) the limitation on the
increase of any penalty applied under
clause (iii).
``(iii) Persistent noncompliance.--In the
case of a specified hospital (other than a
specified hospital that is a hospital or
critical access hospital with 30 or fewer beds)
that the Secretary has determined to be
knowingly and willfully noncompliant with the
provisions of this subsection two or more times
during a 1-year period, the Secretary may
increase any penalty otherwise applicable under
this subparagraph by not more than $1,000,000
and may require such hospital to complete such
additional corrective actions plans as the
Secretary may specify.
``(iv) Application of certain provisions.--
The provisions of section 1128A (other than
subsections (a) and (b) of such section) shall
apply to a civil monetary penalty imposed under
this subparagraph in the same manner as such
provisions apply to a civil monetary penalty
imposed under subsection (a) of such section.
``(v) Authority to waive or reduce
penalty.--The Secretary may waive or reduce any
penalty otherwise applicable with respect to a
specified hospital under this subparagraph if
the Secretary determines that imposition of
such penalty would result in a significant
hardship for such hospital (such as in the case
of a hospital located in a rural or underserved
area where imposition of such penalty may
result in, or contribute to, a lack of access
to care for individuals in such area).
``(C) Publication of hospital price transparency
information.--Beginning on January 1, 2026, the
Secretary shall make publicly available on the public
website of the Centers for Medicare & Medicaid Services
information with respect to compliance with the
requirements of this subsection and enforcement
activities undertaken by the Secretary under this
subsection. Such information shall be updated not less
than annually and include, with respect to each year--
``(i) the number of reviews of compliance
with this subsection undertaken by the
Secretary;
``(ii) the number of notifications
described in subparagraph (A)(i) sent by the
Secretary;
``(iii) the identify of each specified
hospital that was sent such a notification and
a description of the nature of such hospital's
noncompliance with this subsection;
``(iv) the amount of any civil monetary
penalty imposed on such hospital under
subparagraph (B);
``(v) whether such hospital subsequently
came into compliance with this subsection; and
``(vi) any other information as determined
by the Secretary.
``(6) Definitions.--For purposes of this subsection:
``(A) Discounted cash price.--The term `discounted
cash price' means the charge that applies to an
individual who pays cash, or cash equivalent, for a
specified hospital-furnished item or service.
``(B) Federal health care program.--The term
`Federal health care program' has the meaning given
such term in section 1128B.
``(C) Gross charge.--The term `gross charge' means
the charge for an individual item or service that is
reflected on a specified hospital's chargemaster,
absent any discounts.
``(D) Group health plan; group health insurance
coverage; individual health insurance coverage.--The
terms `group health plan', `group health insurance
coverage', and `individual health insurance coverage'
have the meaning given such terms in section 2791 of
the Public Health Service Act.
``(E) Payer-specific negotiated charge.--The term
`payer-specific negotiated charge' means the charge
that a specified hospital has negotiated with a third
party payer for an item or service.
``(F) Shoppable service.--The term `shoppable
service' means a service that can be scheduled by a
health care consumer in advance and includes all
ancillary items and services customarily furnished as
part of such service.
``(G) Specified hospital.--The term `specified
hospital' means a hospital (as defined in section
1861(e)), a critical access hospital (as defined in
section 1861(mmm)(1)), or a rural emergency hospital
(as defined in section 1861(kkk)).
``(H) Third party payer.--The term `third party
payer' means an entity that is, by statute, contract,
or agreement, legally responsible for payment of a
claim for a health care item or service.
``(b) Ambulatory Surgical Center Price Transparency.--
``(1) In general.--Beginning January 1, 2028, each
ambulatory surgical center that receives payment under this
title for furnishing items and services shall comply with the
price transparency requirement described in paragraph (2).
``(2) Requirement described.--
``(A) In general.--For purposes of paragraph (1),
the price transparency requirement described in this
subsection is, with respect to an ambulatory surgical
center, that such surgical center in accordance with a
method and format established by the Secretary under
subparagraph (C)), compile and make public (without
subscription and free of charge), for each year--
``(i) one or more lists, in a format
specified by the Secretary, of the ambulatory
surgical center's standard charges (including
the information described in subparagraph (B))
for each item and service furnished by such
surgical center;
``(ii) information on the ambulatory
surgical center's prices (including the
information described in subparagraph (B)) for
as many of the Centers for Medicare & Medicaid
Services-specified shoppable services that are
furnished by such surgical center, and as many
additional ambulatory surgical center-selected
shoppable services (or all such additional
services, if such surgical center furnishes
fewer than 300 shoppable services) as may be
necessary for a combined total of at least 300
shoppable services;
``(iii) with respect to each Centers for
Medicare & Medicaid Services-specified
shoppable service that is not furnished by the
ambulatory surgical center, an indication that
such service is not so furnished; and
``(iv) any additional information specified
by the Secretary.
``(B) Information described.--For purposes of
subparagraph (A), the information described in this
subparagraph is, with respect to standard charges and
prices (as applicable) made public by an ambulatory
surgical center, the following:
``(i) A description of each item or
service, accompanied by, as applicable, the
Healthcare Common Procedure Coding System code,
the diagnosis-related group, the national drug
code, or other identifier used or approved by
the Centers for Medicare & Medicaid Services.
``(ii) The gross charge, expressed as a
dollar amount, for each such item or service.
``(iii) The discounted cash price,
expressed as a dollar amount, for each such
item or service (or, in the case no discounted
cash price is available for an item or service,
the gross charge for such item or service for
the previous three years, expressed as a dollar
amount).
``(iv) Any other information the Secretary
may require that is not duplicative of any
other reporting requirement under this
subsection for purposes of promoting public
awareness of ambulatory surgical center prices
in advance of receiving an item or service from
such an ambulatory surgical center, which may
include any current payer-specific negotiated
charges, clearly associated with the name of
the third party payer and plan and expressed as
a dollar amount, that applies to each such item
or service.
``(C) Method and format.--Not later than January 1,
2028, the Secretary shall establish one or more methods
and formats for ambulatory surgical centers to use in
making public standard charges and prices (as
applicable) pursuant to subparagraph (A). Any such
method and format--
``(i) may be similar to any template made
available by the Centers for Medicare &
Medicaid Services as of the date of the
enactment of this paragraph;
``(ii) shall meet such standards as
determined appropriate by the Secretary in
order to ensure the accessibility and usability
of such charges and prices; and
``(iii) shall be updated as determined
appropriate by the Secretary, in consultation
with stakeholders.
``(3) Deemed compliance with shoppable services requirement
for ambulatory surgical centers with a price estimator tool.--
``(A) In general.--An ambulatory surgical center
shall be deemed to have complied with the requirement
described in subsection (b)(2)(A) (relating to
shoppable services) if such surgical center maintains a
price estimator tool described in subparagraph (B).
``(B) Price estimator tool described.--For purposes
of subparagraph (A), the price estimator tool described
in this subparagraph is, with respect to an ambulatory
surgical center, a tool that meets the following
requirements:
``(i) Such tool allows an individual to
immediately obtain a price estimate (taking
into account whether such individual is covered
under any plan, coverage, or program described
in clause (iv)(III)) for each Centers for
Medicare & Medicaid Services-specified
shoppable service that is furnished by such
surgical center, and for each additional
shoppable service as such surgical center may
select, such that price estimates are available
through such tool for at least 300 shoppable
services (or for all such services, if such
surgical center furnishes fewer than 300
shoppable services).
``(ii) Such tool allows an individual to
obtain such an estimate by billing code and by
service description.
``(iii) Such tool is prominently displayed
on the public internet website of such
ambulatory surgical center.
``(iv) Such tool does not require an
individual seeking such an estimate to create
an account or otherwise input personal
information, except that such tool may require
that such individual provide information
specified by the Secretary, which may include
the following:
``(I) The name of such individual.
``(II) The date of birth of such
individual.
``(III) In the case such individual
is covered under a group health plan,
group or individual health insurance
coverage, a Federal health care
program, or the program established
under chapter 89 of title 5, United
States Code, an identifying number
assigned by such plan, coverage, or
program to such individual.
``(IV) In the case of an individual
described in subclause (III), an
indication as to whether such
individual is the primary insured
individual under such plan, coverage,
or program (and, if such individual is
not the primary insured individual, a
description of the individual's
relationship to such primary insured
individual).
``(V) Any other information
specified by the Secretary.
``(v) Such tool contains a statement
confirming the accuracy and completeness of
information presented through such tool as of
the date such request is made.
``(vi) Such tool meets any other
requirement specified by the Secretary.
``(4) Monitoring compliance.--The Secretary shall, through
notice and comment rulemaking and in consultation with the
Inspector General of the Department of Health and Human
Services, establish a process to monitor compliance with this
subsection. Such process shall ensure that each ambulatory
surgical center's compliance with this subsection is reviewed
not less frequently than once every 3 years.
``(5) Enforcement.--
``(A) In general.--In the case of an ambulatory
surgical center that fails to comply with the
requirements of this subsection--
``(i) the Secretary shall notify such
ambulatory surgical center of such failure not
later than 30 days after the date on which the
Secretary determines such failure exists; and
``(ii) upon request of the Secretary, the
ambulatory surgical center shall submit to the
Secretary, not later than 45 days after the
date of such request, a corrective action plan
to comply with such requirements.
``(B) Civil monetary penalty.--
``(i) In general.--In addition to any other
enforcement actions or penalties that may apply
under another provision of law, an ambulatory
surgical center that has received a
notification under subparagraph (A)(i) and
fails to comply with the requirements of this
subsection by the date that is 90 days after
such notification (or, in the case of an
ambulatory surgical center that has submitted a
corrective action plan described in
subparagraph (A)(ii) in response to a request
so described, by the date that is 90 days after
such submission) shall be subject to a civil
monetary penalty of an amount specified by the
Secretary for each subsequent day during which
such failure is ongoing (not to exceed $300 per
day).
``(ii) Increase authority.--In applying
this subparagraph with respect to violations
occurring in 2027 or a subsequent year, the
Secretary may through notice and comment
rulemaking increase the limitation on the per
day amount of any penalty applicable to an
ambulatory surgical center under clause (i).
``(iii) Application of certain
provisions.--The provisions of section 1128A
(other than subsections (a) and (b) of such
section) shall apply to a civil monetary
penalty imposed under this subparagraph in the
same manner as such provisions apply to a civil
monetary penalty imposed under subsection (a)
of such section.
``(iv) Authority to waive or reduce
penalty.--The Secretary may waive or reduce any
penalty otherwise applicable with respect to an
ambulatory surgical center under this
subparagraph if the Secretary determines that
imposition of such penalty would result in a
significant hardship for such ambulatory
surgical center (such as in the case of an
ambulatory surgical center located in a rural
or underserved area where imposition of such
penalty may result in, or contribute to, a lack
of access to care for individuals in such
area).
``(6) Definitions.--For purposes of this section:
``(A) Discounted cash price.--The term `discounted
cash price' means the charge that applies to an
individual who pays cash, or cash equivalent, for a
item or service furnished by an ambulatory surgical
center.
``(B) Federal health care program.--The term
`Federal health care program' has the meaning given
such term in section 1128B.
``(C) Gross charge.--The term `gross charge' means
the charge for an individual item or service that is
reflected on a specified surgical center's
chargemaster, absent any discounts.
``(D) Group health plan; group health insurance
coverage; individual health insurance coverage.--The
terms `group health plan', `group health insurance
coverage', and `individual health insurance coverage'
have the meaning given such terms in section 2791 of
the Public Health Service Act.
``(E) Payer-specific negotiated charge.--The term
`payer-specific negotiated charge' means the charge
that a specified surgical center has negotiated with a
third party payer for an item or service.
``(F) Shoppable service.--The term `shoppable
service' means a service that can be scheduled by a
health care consumer in advance and includes all
ancillary items and services customarily furnished as
part of such service.
``(G) Third party payer.--The term `third party
payer' means an entity that is, by statute, contract,
or agreement, legally responsible for payment of a
claim for a health care item or service.
``(c) Imaging Services Price Transparency.--
``(1) In general.--Beginning January 1, 2025, each provider
of services and supplier that receives payment under this title
for furnishing a specified imaging service shall--
``(A) make publicly available (in a form and manner
specified by the Secretary) on an Internet website the
information described in paragraph (2) with respect to
each such service that such provider of services or
supplier furnishes; and
``(B) ensure that such information is updated not
less frequently than annually.
``(2) Information described.--For purposes of paragraph
(1), the information described in this subsection is, with
respect to a provider of services or supplier and a specified
imaging service, the following:
``(A) The discounted cash price for such service
(or, if no such price exists, the gross charge for such
service).
``(B) If required by the Secretary, the
deidentified minimum negotiated rate in effect between
such provider or supplier and any group health plan or
group or individual health insurance coverage for such
service and the deidentified maximum negotiated rate in
effect between such provider or supplier and any such
plan or coverage for such service.
``(3) Method and format.--Not later than January 1, 2028,
the Secretary shall establish one or more methods and formats
for each provider of services and supplier to use in compiling
and making public standard charges and prices (as applicable)
pursuant to paragraph (1). Any such method and format--
``(A) may be similar to any template made available
by the Centers for Medicare & Medicaid Services as of
the date of the enactment of this subsection;
``(B) shall meet such standards as determined
appropriate by the Secretary in order to ensure the
accessibility and usability of such charges and prices;
and
``(C) shall be updated as determined appropriate by
the Secretary, in consultation with stakeholders.
``(4) Monitoring compliance.--The Secretary shall, through
notice and comment rulemaking and in consultation with the
Inspector General of the Department of Health and Human
Services, establish a process to monitor compliance with this
subsection.
``(5) Specification of services.--Not later than January 1,
2025, the Secretary shall publish a list of at least 50 imaging
services that the Secretary determines are shoppable (or all
such services, if the Secretary determines that fewer than 50
such services are shoppable) between providers of services and
suppliers of such services. The Secretary shall update such
list as determined appropriate by the Secretary.
``(6) Enforcement.--
``(A) In general.--In the case that the Secretary
determines that a provider of services or supplier is
not in compliance with paragraph (1)--
``(i) not later than 30 days after such
determination, the Secretary shall notify such
provider or supplier of such determination;
``(ii) upon request of the Secretary, such
provider or supplier shall submit to the
Secretary, not later than 45 days after the
date of such request, a corrective action plan
to comply with such paragraph; and
``(iii) if such provider or supplier
continues to fail to comply with such paragraph
after the date that is 90 days after such
notification is sent (or, in the case of such a
provider or supplier that has submitted a
corrective action plan described in clause (ii)
in response to a request so described, after
the date that is 90 days after such
submission), the Secretary may impose a civil
monetary penalty in an amount not to exceed
$300 for each subsequent day during which such
failure to comply or failure to submit is
ongoing.
``(B) Increase authority.--In applying this
paragraph with respect to violations occurring in 2027
or a subsequent year, the Secretary may through notice
and comment rulemaking increase the amount of the civil
monetary penalty under subparagraph (A)(iii).
``(C) Application of certain provisions.--The
provisions of section 1128A (other than subsections (a)
and (b) of such section) shall apply to a civil
monetary penalty imposed under this paragraph in the
same manner as such provisions apply to a civil
monetary penalty imposed under subsection (a) of such
section.
``(D) Authority to waive or reduce penalty.--The
Secretary may waive or reduce any penalty otherwise
applicable with respect to a provider of services or
supplier under this subparagraph if the Secretary
determines that imposition of such penalty would result
in a significant hardship for such provider or supplier
(such as in the case of a provider or supplier located
in a rural or underserved area where imposition of such
penalty may result in, or contribute to, a lack of
access to care for individuals in such area).
``(E) Clarification of nonapplicability of other
enforcement provisions.--Notwithstanding any other
provision of this title, this paragraph shall be the
sole means of enforcing the provisions of this
subsection.
``(7) Definitions.--In this subsection:
``(A) Group health plan; group health insurance
coverage; individual health insurance coverage.--The
terms `group health plan', `group health insurance
coverage', and `individual health insurance coverage'
have the meaning given such terms in section 2791 of
the Public Health Service Act.
``(B) Specified imaging service.--the term
`specified imaging service' means an imaging service
that is included on the list published by the Secretary
under subsection (e).
``(d) Clinical Laboratory Price Transparency.--
``(1) In general.--Beginning January 1, 2025, each
applicable laboratory that receives payment under this title
for furnishing a specified clinical diagnostic laboratory test
shall--
``(A) make publicly available (in a manner and form
specified by the Secretary) on an Internet website the
information described in paragraph (2) with respect to
each such specified clinical diagnostic laboratory test
that such laboratory is so available to furnish; and
``(B) ensure that such information is updated not
less frequently than annually.
``(2) Information described.--For purposes of paragraph
(1), the information described in this subsection is, with
respect to an applicable laboratory and a specified clinical
diagnostic laboratory test, the following:
``(A) The discounted cash price for such test (or,
if no such price exists, the gross charge for such
test).
``(B) If required by the Secretary, the
deidentified minimum negotiated rate in effect between
such laboratory and any group health plan or group or
individual health insurance coverage for such test and
the deidentified maximum negotiated rate in effect
between such laboratory and any such plan or coverage
for such test.
``(3) Method and format.--Not later than January 1, 2028,
the Secretary shall establish one or more methods and formats
for each provider of services and supplier to use in compiling
and making public standard charges and prices (as applicable)
pursuant to paragraph (1). Any such method and format--
``(A) may be similar to any template made available
by the Centers for Medicare & Medicaid Services as of
the date of the enactment of this subsection;
``(B) shall meet such standards as determined
appropriate by the Secretary in order to ensure the
accessibility and usability of such charges and prices;
and
``(C) shall be updated as determined appropriate by
the Secretary, in consultation with stakeholders.
``(4) Monitoring compliance.--The Secretary shall, through
notice and comment rulemaking and in consultation with the
Inspector General of the Department of Health and Human
Services, establish a process to monitor compliance with this
subsection.
``(5) Enforcement.--
``(A) In general.--In the case that the Secretary
determines that an applicable laboratory is not in
compliance with paragraph (1)--
``(i) not later than 30 days after such
determination, the Secretary shall notify such
laboratory of such determination;
``(ii) upon request of the Secretary, such
laboratory shall submit to the Secretary, not
later than 45 days after such request is sent,
a corrective action plan to comply with such
subsection; and
``(iii) if such laboratory continues to
fail to comply with such paragraph after the
date that is 90 days after such notification is
sent (or, in the case of such a laboratory that
has submitted a corrective action plan
described in clause(ii) in response to a
request so described, after the date that is 90
days after such submission), the Secretary may
impose a civil monetary penalty in an amount
not to exceed $300 for each subsequent day
during which such failure to comply is ongoing.
``(B) Increase authority.--In applying this
paragraph with respect to violations occurring in 2027
or a subsequent year, the Secretary may through notice
and comment rulemaking increase the amount of the civil
monetary penalty under subparagraph (A)(iii).
``(C) Application of certain provisions.--The
provisions of section 1128A (other than subsections (a)
and (b) of such section) shall apply to a civil
monetary penalty imposed under this paragraph in the
same manner as such provisions apply to a civil
monetary penalty imposed under subsection (a) of such
section.
``(D) Authority to waive or reduce penalty.--The
Secretary may waive or reduce any penalty otherwise
applicable with respect to an applicable laboratory
under this paragraph if the Secretary determines that
imposition of such penalty would result in a
significant hardship for such laboratory (such as in
the case of an applicable laboratory located in a rural
or underserved area where imposition of such penalty
may result in, or contribute to, a lack of access to
care for individuals in such area).
``(E) Clarification of nonapplicability of other
enforcement provisions.--Notwithstanding any other
provision of this title, this subsection shall be the
sole means of enforcing the provisions of this section.
``(6) Definitions.--In this subsection:
``(A) Applicable laboratory.--The term `applicable
laboratory' has the meaning given such term in section
414.502, of title 42, Code of Federal Regulations (or
any successor regulation).
``(B) Group health plan; group health insurance
coverage; individual health insurance coverage.--The
terms `group health plan', `group health insurance
coverage', and `individual health insurance coverage'
have the meaning given such terms in section 2791 of
the Public Health Service Act.
``(C) Specified clinical diagnostic laboratory
test.--The term `specified clinical diagnostic
laboratory test' means a clinical diagnostic laboratory
test that is included on the list of shoppable services
specified by the Centers for Medicare & Medicaid
Services pursuant to section 180.60 of title 45, Code
of Federal Regulations (or a successor regulation),
other than such a test that is an advanced diagnostic
laboratory test (as defined in section 1834A(d)(5)).''.
(b) Publication of Hospital Compliance With Price Transparency
Requirements.--Section 1886 of the Social Security Act (42 U.S.C.
1395ww) is amended by adding at the end the following new subsection:
``(u) Publication of Hospital Compliance With Price Transparency
Requirements.--
``(1) In general.--Beginning January 1, 2026, the Secretary
shall, for each hospital with respect to which the Secretary
has conducted a review of such hospital's compliance with the
provisions of section 1899C(a) and found such hospital
noncompliant with such provisions--
``(A) indicate such noncompliance on such
hospital's entry on the Hospital Compare internet
website (or a successor website); and
``(B) specify whether such hospital--
``(i) submitted a corrective action plan
described in subsection (a)(5)(A)(ii) of such
section (and, if so, the date such plan was
received by the Secretary); or
``(ii) was subject to a civil monetary
penalty imposed under subsection (a)(5)(B) of
such section (and, if so, the date of the
imposition of such penalty and the amount of
such penalty).
``(2) Additions and updates.--The Secretary shall update
any specification described in subparagraph (A) or (B) of
paragraph (1) with respect to such hospital--
``(A) in the case of the specification described in
such paragraph (1)(A), as soon as practicable after
sending the notification described in section
1899C(a)(5)(A)(i); and
``(B) in the case of the specification described in
such paragraph (1)(B)(ii), as soon as practicable after
the imposition of a civil monetary penalty described in
such paragraph.''.
(c) Conforming Amendment.--Section 2718(e) of the Public Health
Service Act (42 U.S.C. 300gg-18(e)) is amended by adding at the end the
following new sentence: ``The preceding sentence shall not apply
beginning January 1, 2026.''.
(d) Funding.--
(1) In general.--In addition to funds otherwise available,
out of any moneys in the Treasury not otherwise appropriated,
there are appropriated $10,000,000 for fiscal year 2024, to
remain available until expended, for purposes of--
(A) implementing the amendment made by this
subsection (a); and
(B) monitoring the compliance of entities with such
amendment.
(2) Report on expenditures.--Not later than 5 years after
the date of the enactment of this Act, the Secretary of Health
and Human Services shall submit to the Committee on Ways and
Means and the Committee on Energy and Commerce of the House of
Representatives and the Committee on Finance of the Senate a
report that--
(A) describes activities undertaken funded through
funds made available under paragraph (1), including a
specification of the amount of such funds expended for
each such activity; and
(B) identifies all entities with which the
Secretary has entered into contracts for purposes of
implementing the amendment made by this subsection (a),
monitoring compliance of entities with such amendment,
or providing technical assistance to entities to
promote compliance with such amendment.
(e) Implementation.--
(1) Accessibility.--In implementing section
1899C(a)(2)(A)(ii) of the Social Security Act (as added by
subsection (a)), the Secretary of Health and Human Services
shall through rulemaking ensure that information made available
pursuant to such amendment by an entity is so made available in
plain, easily understandable language and that such entity
provides access to such interpretation services, translations,
and other assistive services to make such information
accessible to individuals with limited English proficiency and
individuals with disabilities.
(2) Technical assistance.--The Secretary of Health and
Human Services shall, to the extent practicable, provide
technical assistance to entities making public standard charges
and prices (as applicable) pursuant to the amendment made by
subsection (a).
SEC. 102. PROMOTING GROUP HEALTH PLAN PRICE TRANSPARENCY.
(a) Price Transparency Requirements.--
(1) IRC.--
(A) In general.--Section 9819 of the Internal
Revenue Code of 1986 (26. U.S.C. 9816) is amended to
read as follows:
``SEC. 9819. PRICE TRANSPARENCY REQUIREMENTS.
``(a) Cost Sharing Transparency.--
``(1) In general.--For plan years beginning on or after the
date that is 2 years after the date of the enactment of the
Health Care Price Transparency Act of 2023, a group health plan
shall permit individuals to learn the amount of cost-sharing
(including deductibles, copayments, and coinsurance) under the
individual's plan or coverage that the individual would be
responsible for paying with respect to the furnishing of a
specific item or service by a provider in a timely manner upon
the request of the individual. At a minimum, such information
shall include the information specified in paragraph (2) and
shall be made available to such individual through a self-
service tool that meets the requirements of paragraph (3) or,
at the option of such individual, through a paper disclosure or
phone or other electronic disclosure (as selected by such
individual and provided at no cost to such individual) that
meets such requirements as the Secretary may specify.
``(2) Specified information.--For purposes of paragraph
(1), the information specified in this paragraph is, with
respect to an item or service for which benefits are available
under a group health plan furnished by a health care provider
to a participant or beneficiary of such plan, the following:
``(A) If such provider is a participating provider
with respect to such item or service, the in-network
rate (as defined in subsection (c)) for such item or
service.
``(B) If such provider is not described in
subparagraph (A), the maximum allowed amount for such
item or service.
``(C) The estimated amount of cost sharing
(including deductibles, copayments, and coinsurance)
that the participant or beneficiary will incur for such
item or service (which, in the case such item or
service is to be furnished by a provider described in
subparagraph (B), shall be calculated using the maximum
amount described in such subparagraph).
``(D) The amount the participant or beneficiary has
already accumulated with respect to any deductible or
out of pocket maximum, whether for items and services
furnished by a participating provider or for items and
services furnished by a provider that is not a
participating provider, under the plan (broken down, in
the case separate deductibles or maximums apply to
separate participants and beneficiaries enrolled in the
plan, by such separate deductibles or maximums, in
addition to any cumulative deductible or maximum).
``(E) In the case such plan imposes any frequency
or volume limitations with respect to such item or
service (excluding medical necessity determinations),
the amount that such participant or beneficiary has
accrued towards such limitation with respect to such
item or service.
``(F) Any prior authorization, concurrent review,
step therapy, fail first, or similar requirements
applicable to coverage of such item or service under
such plan.
The Secretary may provide that information described in any of
subparagraphs (A) through (F) not be treated as information
specified in this paragraph, and specify additional information
that shall be treated as information specified in this
paragraph, if determined appropriate by the Secretary.
``(3) Self-service tool.--For purposes of paragraph (1), a
self-service tool established by a group health plan meets the
requirements of this paragraph if such tool--
``(A) is based on an Internet website;
``(B) provides for real-time responses to requests
described in paragraph (1);
``(C) is updated in a manner such that information
provided through such tool is timely and accurate at
the time such request is made;
``(D) allows such a request to be made with respect
to an item or service furnished by--
``(i) a specific provider that is a
participating provider with respect to such
item or service;
``(ii) all providers that are participating
providers with respect to such item or service;
or
``(iii) a provider that is not described in
clause (ii);
``(E) provides that such a request may be made with
respect to an item or service through use of the
billing code for such item or service or through use of
a descriptive term for such item or service; and
``(F) meets any other requirement determined
appropriate by the Secretary.
The Secretary may require such tool, as a condition of
complying with subparagraph (E), to link multiple billing codes
to a single descriptive term if the Secretary determines that
the billing codes to be so linked correspond to similar items
and services.
``(b) Rate and Payment Information.--
``(1) In general.--For plan years beginning on or after the
date that is 2 years after the date of the enactment of the
Health Care Price Transparency Act of 2023, each group health
plan (other than a grandfathered health plan (as defined in
section 1251(e) of the Patient Protection and Affordable Care
Act) shall, not less frequently than once every 3 months (or,
in the case of information described in paragraph (2)(B), not
less frequently than monthly), make available to the public the
rate and payment information described in paragraph (2) in
accordance with paragraph (3).
``(2) Rate and payment information described.--For purposes
of paragraph (1), the rate and payment information described in
this paragraph is, with respect to a group health plan, the
following:
``(A) With respect to each item or service (other
than a drug) for which benefits are available under
such plan, the in-network rate in effect with each
provider that is a participating provider with respect
to such item or service, other than such a rate in
effect with a provider that, during the 1-year period
ending 10 business days before the date of the
publication of such information, did not submit any
claim for such item or service to such plan.
``(B) With respect to each drug (identified by
national drug code) for which benefits are available
under such plan, the average amount paid by such plan
(net of rebates, discounts, and price concessions) for
such drug dispensed or administered during the 90-day
period beginning 180 days before such date of
publication to each provider that was a participating
provider with respect to such drug, broken down by each
such provider, other than such an amount paid to a
provider that, during such period, submitted fewer than
20 claims for such drug to such plan.
``(C) With respect to each item or service for
which benefits are available under such plan, the
amount billed, and the amount allowed by the plan, for
each such item or service furnished during the 90-day
period specified in subparagraph (B) by a provider that
was not a participating provider with respect to such
item or service, broken down by each such provider,
other than items and services with respect to which
fewer than 20 claims for such item or service were
submitted to such plan during such period.
``(3) Manner of publication.--Rate and payment information
required to be made available under this subsection shall be so
made available in dollar amounts through 3 separate machine-
readable files (or any successor technology, such as
application program interface technology, determined
appropriate by the Secretary) corresponding to the information
described in each of subparagraphs (A) through (C) of paragraph
(2) that meet such requirements as specified by the Secretary.
Such requirements shall ensure that such files are limited to
an appropriate size, do not include disclosure of unnecessary
duplicative information contained in other files made available
under this subsection, are made available in a widely-available
format through a publicly-available website that allows for
information contained in such files to be compared across group
health plans, and are accessible to individuals at no cost and
without the need to establish a user account or provide other
credentials.
``(4) User instructions.--Each group health plan shall make
available to the public instructions written in plain language
explaining how individuals may search for information described
in paragraph (2) in files submitted in accordance with
paragraph (3). The Secretary shall develop and publish a
template that such a plan may use in developing instructions
for purposes of the preceding sentence.
``(5) Attestation.--Each group health plan shall post,
along with rate and payment information made public by such
plan, an attestation that such information is complete and
accurate.
``(c) Definitions.--In this section:
``(1) Participating provider.--The term `participating
provider' has the meaning given such term in section 9816.
``(2) In-network rate.--The term `in-network rate' means,
with respect to a health plan and an item or service furnished
by a provider that is a participating provider with respect to
such plan and item or service, the contracted rate in effect
between such plan and such provider for such item or
service.''.
(B) Clerical amendment.--The item relating to
section 9819 of the table of sections for subchapter B
of chapter 100 of the Internal Revenue Code of 1986 is
amended to read as follows:
``Sec. 9819. Price transparency requirements.''.
(2) PHSA.--Section 2799A-4 of the Public Health Service Act
(42 U.S.C. 300gg-114) is amended to read as follows:
``SEC. 2799A-4. PRICE TRANSPARENCY REQUIREMENTS.
``(a) Cost Sharing Transparency.--
``(1) In general.--For plan years beginning on or after the
date that is 2 years after the date of the enactment of the
Health Care Price Transparency Act of 2023, a group health plan
or a health insurance issuer offering group or individual
health insurance coverage shall permit individuals to learn the
amount of cost-sharing (including deductibles, copayments, and
coinsurance) under the individual's plan or coverage that the
individual would be responsible for paying with respect to the
furnishing of a specific item or service by a provider in a
timely manner upon the request of the individual. At a minimum,
such information shall include the information specified in
paragraph (2) and shall be made available to such individual
through a self-service tool that meets the requirements of
paragraph (3) or, at the option of such individual, through a
paper disclosure or phone or other electronic disclosure (as
selected by such individual and provided at no cost to such
individual) that meets such requirements as the Secretary may
specify.
``(2) Specified information.--For purposes of paragraph
(1), the information specified in this paragraph is, with
respect to an item or service for which benefits are available
under a group health plan or group or individual health
insurance coverage furnished by a health care provider to a
participant or beneficiary of such plan, or enrollee in such
coverage, the following:
``(A) If such provider is a participating provider
with respect to such item or service, the in-network
rate (as defined in subsection (c)) for such item or
service.
``(B) If such provider is not described in
subparagraph (A), the maximum allowed amount for such
item or service.
``(C) The estimated amount of cost sharing
(including deductibles, copayments, and coinsurance)
that the participant or beneficiary will incur for such
item or service (which, in the case such item or
service is to be furnished by a provider described in
subparagraph (B), shall be calculated using the maximum
amount described in such subparagraph).
``(D) The amount the participant, beneficiary, or
enrollee has already accumulated with respect to any
deductible or out of pocket maximum, whether for items
and services furnished by a participating provider or
for items and services furnished by a provider that is
not a participating provider, under the plan or
coverage (broken down, in the case separate deductibles
or maximums apply to separate participants,
beneficiaries or enrollees enrolled in the plan or
coverage, by such separate deductibles or maximums, in
addition to any cumulative deductible or maximum).
``(E) In the case such plan or coverage imposes any
frequency or volume limitations with respect to such
item or service (excluding medical necessity
determinations), the amount that such participant,
beneficiary, or enrollee has accrued towards such
limitation with respect to such item or service.
``(F) Any prior authorization, concurrent review,
step therapy, fail first, or similar requirements
applicable to coverage of such item or service under
such plan or coverage.
The Secretary may provide that information described in any of
subparagraphs (A) through (F) not be treated as information
specified in this paragraph, and specify additional information
that shall be treated as information specified in this
paragraph, if determined appropriate by the Secretary.
``(3) Self-service tool.--For purposes of paragraph (1), a
self-service tool established by a group health plan or group
or individual health insurance coverage meets the requirements
of this paragraph if such tool--
``(A) is based on an Internet website;
``(B) provides for real-time responses to requests
described in paragraph (1);
``(C) is updated in a manner such that information
provided through such tool is timely and accurate at
the time such request is made;
``(D) allows such a request to be made with respect
to an item or service furnished by--
``(i) a specific provider that is a
participating provider with respect to such
item or service;
``(ii) all providers that are participating
providers with respect to such item or service;
or
``(iii) a provider that is not described in
clause (ii);
``(E) provides that such a request may be made with
respect to an item or service through use of the
billing code for such item or service or through use of
a descriptive term for such item or service; and
``(F) meets any other requirement determined
appropriate by the Secretary.
The Secretary may require such tool, as a condition of
complying with subparagraph (E), to link multiple billing codes
to a single descriptive term if the Secretary determines that
the billing codes to be so linked correspond to similar items
and services.
``(b) Rate and Payment Information.--
``(1) In general.--For plan years beginning on or after the
date that is 2 years after the date of the enactment of the
Health Care Price Transparency Act of 2023, each group health
plan (other than a grandfathered health plan (as defined in
section 1251(e) of the Patient Protection and Affordable Care
Act) or group or individual health insurance coverage, shall,
not less frequently than once every 3 months (or, in the case
of information described in paragraph (2)(B), not less
frequently than monthly), make available to the public the rate
and payment information described in paragraph (2) in
accordance with paragraph (3).
``(2) Rate and payment information described.--For purposes
of paragraph (1), the rate and payment information described in
this paragraph is, with respect to a group health plan or group
or individual health insurance coverage, the following:
``(A) With respect to each item or service (other
than a drug) for which benefits are available under
such plan or coverage, the in-network rate in effect
with each provider that is a participating provider
with respect to such item or service, other than such a
rate in effect with a provider that, during the 1-year
period ending 10 business days before the date of the
publication of such information, did not submit any
claim for such item or service to such plan or
coverage.
``(B) With respect to each drug (identified by
national drug code) for which benefits are available
under such plan, the average amount paid by such plan
or coverage (net of rebates, discounts, and price
concessions) for such drug dispensed or administered
during the 90-day period beginning 180 days before such
date of publication to each provider that was a
participating provider with respect to such drug,
broken down by each such provider, other than such an
amount paid to a provider that, during such period,
submitted fewer than 20 claims for such drug to such
plan or coverage.
``(C) With respect to each item or service for
which benefits are available under such plan or
coverage, the amount billed, and the amount allowed by
the plan 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, 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.
``(3) Manner of publication.--Rate and payment information
required to be made available under this subsection shall be so
made available in dollar amounts through 3 separate machine-
readable files (or any successor technology, such as
application program interface technology, determined
appropriate by the Secretary) corresponding to the information
described in each of subparagraphs (A) through (C) of paragraph
(2) that meet such requirements as specified by the Secretary.
Such requirements shall ensure that such files are limited to
an appropriate size, do not include disclosure of unnecessary
duplicative information contained in other files made available
under this subsection, are made available in a widely-available
format through a publicly-available website that allows for
information contained in such files to be compared across group
health plans and group and individual health insurance
coverage, and are accessible to individuals at no cost and
without the need to establish a user account or provide other
credentials.
``(4) User instructions.--Each group health plan and group
or individual health insurance coverage shall make available to
the public instructions written in plain language explaining
how individuals may search for information described in
paragraph (2) in files submitted in accordance with paragraph
(3). The Secretary shall develop and publish a template that
such a plan or coverage may use in developing instructions for
purposes of the preceding sentence.
``(5) Attestation.--Each group health plan and group or
individual health insurance coverage shall post, along with
rate and payment information made public by such plan or
coverage, an attestation that such information is complete and
accurate.
``(c) Definitions.--In this section:
``(1) Participating provider.--The term `participating
provider' has the meaning given such term in section 2791A-
1(a)(3)(G)(ii).
``(2) In-network rate.--The term `in-network rate' means,
with respect to a health plan or coverage and an item or
service furnished by a provider that is a participating
provider with respect to such plan and item or service, the
contracted rate in effect between such plan or coverage and
such provider for such item or service.''.
(3) ERISA.--
(A) In general.--Section 719 of the Employee
Retirement Income Security Act of 1974 (29 U.S.C.
1185h) is amended to read as follows:
``SEC. 719. PRICE TRANSPARENCY REQUIREMENTS.
``(a) Cost Sharing Transparency.--
``(1) In general.--For plan years beginning on or after the
date that is 2 years after the date of the enactment of the
Health Care Price Transparency Act of 2023, a group health plan
or a health insurance issuer offering group health insurance
coverage shall permit individuals to learn the amount of cost-
sharing (including deductibles, copayments, and coinsurance)
under the individual's plan or coverage that the individual
would be responsible for paying with respect to the furnishing
of a specific item or service by a provider in a timely manner
upon the request of the individual. At a minimum, such
information shall include the information specified in
paragraph (2) and shall be made available to such individual
through a self-service tool that meets the requirements of
paragraph (3) or, at the option of such individual, through a
paper disclosure or phone or other electronic disclosure (as
selected by such individual and provided at no cost to such
individual) that meets such requirements as the Secretary may
specify.
``(2) Specified information.--For purposes of paragraph
(1), the information specified in this paragraph is, with
respect to an item or service for which benefits are available
under a group health plan or group health insurance coverage
furnished by a health care provider to a participant or
beneficiary of such plan, or enrollee in such coverage, the
following:
``(A) If such provider is a participating provider
with respect to such item or service, the in-network
rate (as defined in subsection (c)) for such item or
service.
``(B) If such provider is not described in
subparagraph (A), the maximum allowed amount for such
item or service.
``(C) The estimated amount of cost sharing
(including deductibles, copayments, and coinsurance)
that the participant or beneficiary will incur for such
item or service (which, in the case such item or
service is to be furnished by a provider described in
subparagraph (B), shall be calculated using the maximum
amount described in such subparagraph).
``(D) The amount the participant, beneficiary, or
enrollee has already accumulated with respect to any
deductible or out of pocket maximum, whether for items
and services furnished by a participating provider or
for items and services furnished by a provider that is
not a participating provider, under the plan or
coverage (broken down, in the case separate deductibles
or maximums apply to separate participants,
beneficiaries or enrollees enrolled in the plan or
coverage, by such separate deductibles or maximums, in
addition to any cumulative deductible or maximum).
``(E) In the case such plan or coverage imposes any
frequency or volume limitations with respect to such
item or service (excluding medical necessity
determinations), the amount that such participant,
beneficiary, or enrollee has accrued towards such
limitation with respect to such item or service.
``(F) Any prior authorization, concurrent review,
step therapy, fail first, or similar requirements
applicable to coverage of such item or service under
such plan or coverage.
The Secretary may provide that information described in any of
subparagraphs (A) through (F) not be treated as information
specified in this paragraph, and specify additional information
that shall be treated as information specified in this
paragraph, if determined appropriate by the Secretary.
``(3) Self-service tool.--For purposes of paragraph (1), a
self-service tool established by a group health plan or group
health insurance coverage meets the requirements of this
paragraph if such tool--
``(A) is based on an Internet website;
``(B) provides for real-time responses to requests
described in paragraph (1);
``(C) is updated in a manner such that information
provided through such tool is timely and accurate at
the time such request is made;
``(D) allows such a request to be made with respect
to an item or service furnished by--
``(i) a specific provider that is a
participating provider with respect to such
item or service;
``(ii) all providers that are participating
providers with respect to such item or service;
or
``(iii) a provider that is not described in
clause (ii);
``(E) provides that such a request may be made with
respect to an item or service through use of the
billing code for such item or service or through use of
a descriptive term for such item or service; and
``(F) meets any other requirement determined
appropriate by the Secretary.
The Secretary may require such tool, as a condition of
complying with subparagraph (E), to link multiple billing codes
to a single descriptive term if the Secretary determines that
the billing codes to be so linked correspond to similar items
and services.
``(b) Rate and Payment Information.--
``(1) In general.--For plan years beginning on or after the
date that is 2 years after the date of the enactment of the
Health Care Price Transparency Act of 2023, each group health
plan (other than a grandfathered health plan (as defined in
section 1251(e) of the Patient Protection and Affordable Care
Act) or group health insurance coverage, shall, not less
frequently than once every 3 months (or, in the case of
information described in paragraph (2)(B), not less frequently
than monthly), make available to the public the rate and
payment information described in paragraph (2) in accordance
with paragraph (3).
``(2) Rate and payment information described.--For purposes
of paragraph (1), the rate and payment information described in
this paragraph is, with respect to a group health plan or group
health insurance coverage, the following:
``(A) With respect to each item or service (other
than a drug) for which benefits are available under
such plan or coverage, the in-network rate in effect
with each provider that is a participating provider
with respect to such item or service, other than such a
rate in effect with a provider that, during the 1-year
period ending 10 business days before the date of the
publication of such information, did not submit any
claim for such item or service to such plan or
coverage.
``(B) With respect to each drug (identified by
national drug code) for which benefits are available
under such plan, the average amount paid by such plan
or coverage (net of rebates, discounts, and price
concessions) for such drug dispensed or administered
during the 90-day period beginning 180 days before such
date of publication to each provider that was a
participating provider with respect to such drug,
broken down by each such provider, other than such an
amount paid to a provider that, during such period,
submitted fewer than 20 claims for such drug to such
plan or coverage.
``(C) With respect to each item or service for
which benefits are available under such plan or
coverage, the amount billed, and the amount allowed by
the plan 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, 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.
``(3) Manner of publication.--Rate and payment information
required to be made available under this subsection shall be so
made available in dollar amounts through 3 separate machine-
readable files (or any successor technology, such as
application program interface technology, determined
appropriate by the Secretary) corresponding to the information
described in each of subparagraphs (A) through (C) of paragraph
(2) that meet such requirements as specified by the Secretary.
Such requirements shall ensure that such files are limited to
an appropriate size, do not include disclosure of unnecessary
duplicative information contained in other files made available
under this subsection, are made available in a widely-available
format through a publicly-available website that allows for
information contained in such files to be compared across group
health plans and group and individual health insurance
coverage, and are accessible to individuals at no cost and
without the need to establish a user account or provide other
credentials.
``(4) User instructions.--Each group health plan and group
health insurance coverage shall make available to the public
instructions written in plain language explaining how
individuals may search for information described in paragraph
(2) in files submitted in accordance with paragraph (3). The
Secretary shall develop and publish a template that such a plan
or coverage may use in developing instructions for purposes of
the preceding sentence.
``(5) Attestation.--Each group health plan and group health
insurance coverage shall post, along with rate and payment
information made public by such plan or coverage, an
attestation that such information is complete and accurate.
``(c) Definitions.--In this section:
``(1) Participating provider.--The term `participating
provider' has the meaning given such term in section
716(a)(3)(G)(ii).
``(2) In-network rate.--The term `in-network rate' means,
with respect to a health plan or coverage and an item or
service furnished by a provider that is a participating
provider with respect to such plan and item or service, the
contracted rate in effect between such plan or coverage and
such provider for such item or service.''.
(B) Clerical amendment.--The table of contents in
section 1 of the Employee Retirement Income Security
Act of 1974 is amended by striking the item relating to
section 719 and inserting the following new item:
``Sec. 719. Price transparency requirements.''.
(b) Accessibility Through Implementation.--In implementing the
amendments made by subsection (a), the Secretary of the Treasury, the
Secretary of Health and Human Services, and the Secretary of Labor
shall take reasonable steps to ensure the accessibility of information
made available pursuant to such amendments, including reasonable steps
to ensure that such information is provided in plain, easily
understandable language and that interpretation, translations, and
assistive services are provided by group health plans and health
insurance issuers offering group or individual health insurance
coverage to make such information accessible to those with limited
English proficiency and those with disabilities.
(c) Continued Applicability of Rules for Previous Years.--Nothing
in the amendments made by subsection (a) may be construed as affecting
the applicability of the rule entitled ``Transparency in Coverage''
published by the Department of the Treasury, the Department of Labor,
and the Department of Health and Human Services on November 12, 2020
(85 Fed. Reg. 72158) for any plan year beginning before the date that
is 2 years after the date of the enactment of this Act.
SEC. 103. OVERSIGHT OF PHARMACY BENEFITS MANAGER SERVICES.
(a) IRC.--
(1) In general.--Subchapter B of chapter 100 of the
Internal Revenue Code of 1986 is amended by adding at the end
the following:
``SEC. 9826. OVERSIGHT OF PHARMACY BENEFITS MANAGER SERVICES.
``(a) In General.--For plan years beginning on or after the date
that is 3 years after the date of enactment of this section, a group
health plan, or an entity or subsidiary providing pharmacy benefits
management services on behalf of such a plan, shall not enter into a
contract with a drug manufacturer, distributor, wholesaler,
subcontractor, rebate aggregator, or any associated third party that
limits the disclosure of information to plan sponsors 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 the
report described in subsection (b).
``(b) Annual Report.--
``(1) In general.--With respect to plan years beginning on
or after the date that is 3 years after the date of enactment
of this section, for each such plan year, a group health plan,
or an entity providing pharmacy benefits management services on
behalf of such a plan, shall submit to the plan sponsor (as
defined in section 3(16)(B) of the Employee Retirement Income
Security Act of 1974) of such plan a report in a machine-
readable format. Each such report shall include, with respect
to such plan provided for such plan year--
``(A) to the extent feasible, information collected
from drug manufacturers (or an entity administering
copay assistance on behalf of such manufacturers) by
such plan (or entity or subsidiary providing pharmacy
benefits management services on behalf of such plan) on
the total amount of copayment assistance dollars paid,
or copayment cards applied, that were funded by the
drug manufacturer with respect to the participants and
beneficiaries in such plan;
``(B) a list of each drug covered by such plan that
was dispensed during the plan year, including, with
respect to each such drug during such plan year--
``(i) the brand name, chemical entity, and
National Drug Code;
``(ii) the number of participants and
beneficiaries for whom the drug was dispensed
during the plan year, the total number of
prescription claims for the drug (including
original prescriptions and refills), and the
total number of dosage units of the drug
dispensed across the plan year, disaggregated
by dispensing channel (such as retail, mail
order, or specialty pharmacy);
``(iii) the wholesale acquisition cost,
listed as cost per days supply and cost per
pill, or in the case of a drug in another form,
per dosage unit;
``(iv) the total out-of-pocket spending by
participants and beneficiaries on such drug,
including participant and beneficiary spending
through copayments, coinsurance, and
deductibles;
``(v) for any drug for which gross spending
of the group health plan exceeded $10,000
during the plan year--
``(I) a list of all other drugs in
the same therapeutic category or class,
including brand name drugs and
biological products and generic drugs
or biosimilar biological products that
are in the same therapeutic category or
class as such drug; and
``(II) the rationale for the
formulary placement of such drug in
that therapeutic category or class, if
applicable;
``(vi) the amount received, or expected to
be received, from drug manufacturers in
rebates, fees, alternative discounts, or other
remuneration for claims incurred for such drug
during the plan year;
``(vii) the total net spending, after
deducting rebates, price concessions,
alternative discounts or other remuneration
from drug manufacturers, by the health plan on
such drug; and
``(viii) the net price per course of
treatment or single fill, such as a 30-day
supply or 90-day supply, incurred by the health
plan and its participants and beneficiaries
after manufacturer rebates, fees, and other
remuneration for such drug dispensed during the
plan year;
``(C) a list of each therapeutic category or class
of drugs that were dispensed under the health plan
during the plan year, and, with respect to each such
therapeutic category or class of drugs, during the plan
year--
``(i) total gross spending by the plan,
before manufacturer rebates, fees, or other
manufacturer remuneration;
``(ii) the number of participants and
beneficiaries who were dispensed a drug covered
by such plan in that category or class, broken
down by each such drug (identified by National
Drug Code);
``(iii) if applicable to that category or
class, a description of the formulary tiers and
utilization management (such as prior
authorization or step therapy) employed for
drugs in that category or class; and
``(iv) the total out-of-pocket spending by
participants and beneficiaries, including
participant and beneficiary spending through
copayments, coinsurance, and deductibles;
``(D) total gross spending on prescription drugs by
the plan during the plan year, before rebates and other
manufacturer fees or remuneration;
``(E) total amount received, or expected to be
received, by the health plan in drug manufacturer
rebates, fees, alternative discounts, and all other
remuneration received from the manufacturer or any
third party, other than the plan sponsor, related to
utilization of drug or drug spending under that health
plan during the plan year;
``(F) the total net spending on prescription drugs
by the health plan during the plan year; and
``(G) amounts paid directly or indirectly in
rebates, fees, or any other type of remuneration to
brokers, consultants, advisors, or any other individual
or firm for the referral of the group health plan's
business to the pharmacy benefits manager.
``(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 sponsors 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 group health plan, 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 sponsor 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), and such other information
that the Comptroller General determines necessary to carry out
the study under section 103(d) of the Health Care Price
Transparency Act of 2023.
``(5) Standard format.--Not later than 18 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) 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 Secretary of the
Treasury to a report described in subsection (b)(1) or information
related to compliance with subsection (a) or (b) by such plan or other
entity subject to such subsections.
``(d) Definition.--In this section, 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.''.
(b) PHSA.--Title XXVII of the Public Health Service Act (42 U.S.C.
300gg et seq.) is amended--
(1) in part D (42 U.S.C. 300gg-111 et seq.), by adding at
the end the following new section:
``SEC. 2799A-11. OVERSIGHT OF PHARMACY BENEFITS MANAGER SERVICES.
``(a) In General.--For plan years beginning on or after the date
that is 3 years after the date of enactment of this section, a group
health plan or health insurance issuer offering group health insurance
coverage, or an entity or subsidiary providing pharmacy benefits
management services on behalf of such a plan or issuer, shall not enter
into a contract with a drug manufacturer, distributor, wholesaler,
subcontractor, rebate aggregator, or any associated third party that
limits the disclosure of information to plan sponsors 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 the report described in subsection (b).
``(b) Annual Report.--
``(1) In general.--With respect to plan years beginning on
or after the date that is 3 years after the date of enactment
of this section, for each such plan year, a group health plan
or health insurance issuer offering group health insurance
coverage, or an entity providing pharmacy benefits management
services on behalf of such a plan or an issuer, shall submit to
the plan sponsor (as defined in section 3(16)(B) of the
Employee Retirement Income Security Act of 1974) of such plan
or coverage a report in a machine-readable format. Each such
report shall include, with respect to such plan or coverage
provided for such plan year--
``(A) to the extent feasible, information collected
from drug manufacturers (or an entity administering
copay assistance on behalf of such manufacturers) by
such plan or issuer (or entity or subsidiary providing
pharmacy benefits management services on behalf of such
plan or issuer) on the total amount of copayment
assistance dollars paid, or copayment cards applied,
that were funded by the drug manufacturer with respect
to the participants, beneficiaries, and enrollees in
such plan or coverage;
``(B) a list of each drug covered by such plan or
coverage that was dispensed during the plan year,
including, with respect to each such drug during such
plan year--
``(i) the brand name, chemical entity, and
National Drug Code;
``(ii) the number of participants,
beneficiaries, and enrollees for whom the drug
was dispensed during the plan year, the total
number of prescription claims for the drug
(including original prescriptions and refills),
and the total number of dosage units of the
drug dispensed across the plan year,
disaggregated by dispensing channel (such as
retail, mail order, or specialty pharmacy);
``(iii) the wholesale acquisition cost,
listed as cost per days supply and cost per
pill, or in the case of a drug in another form,
per dosage unit;
``(iv) the total out-of-pocket spending by
participants, beneficiaries, and enrollees on
such drug, including participant, beneficiary,
and enrollee spending through copayments,
coinsurance, and deductibles;
``(v) for any drug for which gross spending
of the group health plan or health insurance
coverage exceeded $10,000 during the plan
year--
``(I) a list of all other drugs in
the same therapeutic category or class,
including brand name drugs and
biological products and generic drugs
or biosimilar biological products that
are in the same therapeutic category or
class as such drug; and
``(II) the rationale for the
formulary placement of such drug in
that therapeutic category or class, if
applicable;
``(vi) the amount received, or expected to
be received, from drug manufacturers in
rebates, fees, alternative discounts, or other
remuneration for claims incurred for such drug
during the plan year;
``(vii) 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 such drug; and
``(viii) the net price per course of
treatment or single fill, such as a 30-day
supply or 90-day supply, incurred by the health
plan or health insurance coverage and its
participants, beneficiaries, and enrollees,
after manufacturer rebates, fees, and other
remuneration for such drug dispensed during the
plan year;
``(C) a list of each therapeutic category or class
of drugs that were dispensed under the health plan or
health insurance coverage during the plan year, and,
with respect to each such therapeutic category or class
of drugs, during the plan year--
``(i) total gross spending by the plan or
coverage, before manufacturer rebates, fees, or
other manufacturer remuneration;
``(ii) the number of participants,
beneficiaries, and enrollees who were dispensed
a drug covered by such plan or coverage in that
category or class, broken down by each such
drug (identified by National Drug Code);
``(iii) if applicable to that category or
class, a description of the formulary tiers and
utilization management (such as prior
authorization or step therapy) employed for
drugs in that category or class; and
``(iv) the total out-of-pocket spending by
participants, beneficiaries, and enrollees,
including participant, beneficiary, and
enrollee spending through copayments,
coinsurance, and deductibles;
``(D) total gross spending on prescription drugs by
the plan or coverage during the plan year, before
rebates and other manufacturer fees or remuneration;
``(E) total amount received, or expected to be
received, by the health plan or health insurance
coverage in drug manufacturer rebates, fees,
alternative discounts, and all other remuneration
received from the manufacturer or any third party,
other than the plan sponsor, related to utilization of
drug or drug spending under that health plan or health
insurance coverage during the plan year;
``(F) the total net spending on prescription drugs
by the health plan or health insurance coverage during
the plan year; and
``(G) amounts paid directly or indirectly in
rebates, fees, or any other type of remuneration to
brokers, consultants, advisors, or any other individual
or firm for the referral of the group health plan's or
health insurance issuer's business to the pharmacy
benefits manager.
``(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 sponsors 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 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 shall submit to the Comptroller
General of the United States each of the first 4 reports
submitted to a plan sponsor 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), and such
other information that the Comptroller General determines
necessary to carry out the study under section 103(d) of the
Health Care Price Transparency Act of 2023.
``(5) Standard format.--Not later than 18 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) In general.--Notwithstanding section 2723, the
Secretary, in consultation with the Secretary of Labor and the
Secretary of the Treasury, shall enforce this section.
``(2) Failure to provide timely information.--A health
insurance issuer or 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.
``(3) False information.--A health insurance issuer or
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.
``(4) 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.
``(5) Waivers.--The Secretary may waive penalties under
paragraph (2), or extend the period of time for compliance with
a requirement of this section, for an entity in violation of
this section that has made a good-faith effort to comply with
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 Secretary of Health and Human Services to a report described in
subsection (b)(1) or information related to compliance with subsection
(a) or (b) by such issuer, plan, or other entity subject to such
subsections.
``(e) Definition.--In this section, the term `wholesale acquisition
cost' has the meaning given such term in section 1847A(c)(6)(B) of the
Social Security Act.''; and
(2) in section 2723 of such Act (42 U.S.C. 300gg-22)--
(A) in subsection (a)--
(i) in paragraph (1), by inserting ``(other
than subsections (a) and (b) of section 2799A-
11)'' after ``part D''; and
(ii) in paragraph (2), by inserting
``(other than subsections (a) and (b) of
section 2799A-11)'' after ``part D''; and
(B) in subsection (b)--
(i) in paragraph (1), by inserting ``(other
than subsections (a) and (b) of section 2799A-
11)'' after ``part D'';
(ii) in paragraph (2)(A), by inserting
``(other than subsections (a) and (b) of
section 2799A-11)'' after ``part D''; and
(iii) in paragraph (2)(C)(ii), by inserting
``(other than subsections (a) and (b) of
section 2799A-11)'' after ``part D''.
(c) 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 the date
that is 3 years after the date of enactment of this section, a group
health plan or health insurance issuer offering group health insurance
coverage, or an entity or subsidiary providing pharmacy benefits
management services on behalf of such a plan or issuer, shall not enter
into a contract with a drug manufacturer, distributor, wholesaler,
subcontractor, rebate aggregator, or any associated third party that
limits the disclosure of information to plan sponsors 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 the report described in subsection (b).
``(b) Annual Report.--
``(1) In general.--With respect to plan years beginning on
or after the date that is 3 years after the date of enactment
of this section, for each such plan year, a group health plan
or health insurance issuer offering group health insurance
coverage, or an entity providing pharmacy benefits management
services on behalf of such a plan or an issuer, shall submit to
the plan sponsor (as defined in section 3(16)(B)) of such plan
or coverage a report in a machine-readable format. Each such
report shall include, with respect to such plan or coverage
provided for such plan year--
``(A) to the extent feasible, information collected
from drug manufacturers (or an entity administering
copay assistance on behalf of such manufacturers) by
such plan or issuer (or entity or subsidiary providing
pharmacy benefits management services on behalf of such
plan or issuer) on the total amount of copayment
assistance dollars paid, or copayment cards applied,
that were funded by the drug manufacturer with respect
to the participants, beneficiaries, and enrollees in
such plan or coverage;
``(B) a list of each drug covered by such plan or
coverage that was dispensed during the plan year,
including, with respect to each such drug during such
plan year--
``(i) the brand name, chemical entity, and
National Drug Code;
``(ii) the number of participants,
beneficiaries, and enrollees for whom the drug
was dispensed during the plan year, the total
number of prescription claims for the drug
(including original prescriptions and refills),
and the total number of dosage units of the
drug dispensed across the plan year,
disaggregated by dispensing channel (such as
retail, mail order, or specialty pharmacy);
``(iii) the wholesale acquisition cost,
listed as cost per days supply and cost per
pill, or in the case of a drug in another form,
per dosage unit;
``(iv) the total out-of-pocket spending by
participants, beneficiaries, and enrollees on
such drug, including participant, beneficiary,
and enrollee spending through copayments,
coinsurance, and deductibles;
``(v) for any drug for which gross spending
of the group health plan or health insurance
coverage exceeded $10,000 during the plan
year--
``(I) a list of all other drugs in
the same therapeutic category or class,
including brand name drugs and
biological products and generic drugs
or biosimilar biological products that
are in the same therapeutic category or
class as such drug; and
``(II) the rationale for the
formulary placement of such drug in
that therapeutic category or class, if
applicable;
``(vi) the amount received, or expected to
be received, from drug manufacturers in
rebates, fees, alternative discounts, or other
remuneration for claims incurred for such drug
during the plan year;
``(vii) 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 such drug; and
``(viii) the net price per course of
treatment or single fill, such as a 30-day
supply or 90-day supply, incurred by the health
plan or health insurance coverage and its
participants, beneficiaries, and enrollees,
after manufacturer rebates, fees, and other
remuneration for such drug dispensed during the
plan year;
``(C) a list of each therapeutic category or class
of drugs that were dispensed under the health plan or
health insurance coverage during the plan year, and,
with respect to each such therapeutic category or class
of drugs, during the plan year--
``(i) total gross spending by the plan or
coverage, before manufacturer rebates, fees, or
other manufacturer remuneration;
``(ii) the number of participants,
beneficiaries, and enrollees who were dispensed
a drug covered by such plan or coverage in that
category or class, broken down by each such
drug (identified by National Drug Code);
``(iii) if applicable to that category or
class, a description of the formulary tiers and
utilization management (such as prior
authorization or step therapy) employed for
drugs in that category or class; and
``(iv) the total out-of-pocket spending by
participants, beneficiaries, and enrollees,
including participant, beneficiary, and
enrollee spending through copayments,
coinsurance, and deductibles;
``(D) total gross spending on prescription drugs by
the plan or coverage during the plan year, before
rebates and other manufacturer fees or remuneration;
``(E) total amount received, or expected to be
received, by the health plan or health insurance
coverage in drug manufacturer rebates, fees,
alternative discounts, and all other remuneration
received from the manufacturer or any third party,
other than the plan sponsor, related to utilization of
drug or drug spending under that health plan or health
insurance coverage during the plan year;
``(F) the total net spending on prescription drugs
by the health plan or health insurance coverage during
the plan year; and
``(G) amounts paid directly or indirectly in
rebates, fees, or any other type of remuneration to
brokers, consultants, advisors, or any other individual
or firm for the referral of the group health plan's or
health insurance issuer's business to the pharmacy
benefits manager.
``(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 sponsors 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 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 shall submit to the Comptroller
General of the United States each of the first 4 reports
submitted to a plan sponsor 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), and such
other information that the Comptroller General determines
necessary to carry out the study under section 103(d) of the
Health Care Price Transparency Act of 2023.
``(5) Standard format.--Not later than 18 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) In general.--Notwithstanding section 502, the
Secretary, in consultation with the Secretary of Health and
Human Services and the Secretary of the Treasury, shall enforce
this section.
``(2) Failure to provide timely information.--A health
insurance issuer or 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.
``(3) False information.--A health insurance issuer or
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.
``(4) 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.
``(5) Waivers.--The Secretary may waive penalties under
paragraph (2), or extend the period of time for compliance with
a requirement of this section, for an entity in violation of
this section that has made a good-faith effort to comply with
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 Secretary of Labor to a report described in subsection (b)(1)
or information related to compliance with subsection (a) or (b) by such
issuer, plan, or other entity subject to such subsections.
``(e) Definition.--In this section, 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, in consultation with the Secretary
of Health and Human Services, and the Secretary of the
Treasury, 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, in consultation with the Secretary of Health
and Human Services and the Secretary of the Treasury,
may impose a penalty against any group health plan or
health insurance issuer offering group health insurance
coverage, or entity providing pharmacy benefits
management services on behalf of such plan or coverage,
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, in
consultation with the Secretary of Health and Human
Services and the Secretary of the Treasury, may impose
a penalty against a group health plan or health
insurance issuer offering group health coverage, or an
entity providing pharmacy benefits management services
on behalf of such plan or coverage, 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.''.
(d) GAO Study.--
(1) In general.--Not later than 3 years after the date of
enactment of this Act, the Comptroller General of the United
States shall submit to Congress a report on--
(A) pharmacy networks of group health plans, health
insurance issuers, and entities providing pharmacy
benefits management services under such group health
plan or group or individual health insurance coverage,
including networks that have pharmacies that are under
common ownership (in whole or part) with group health
plans, health insurance issuers, or entities providing
pharmacy benefits management services or pharmacy
benefits administrative services under group health
plan or group or individual health insurance coverage;
(B) as it relates to pharmacy networks that include
pharmacies under common ownership described in
subparagraph (A)--
(i) whether such networks are designed to
encourage enrollees of a plan or coverage to
use such pharmacies over other network
pharmacies for specific services or drugs, and
if so, the reasons the networks give for
encouraging use of such pharmacies; and
(ii) whether such pharmacies are used by
enrollees disproportionately more in the
aggregate or for specific services or drugs
compared to other network pharmacies;
(C) whether group health plans and health insurance
issuers offering group or individual health insurance
coverage have options to elect different network
pricing arrangements in the marketplace with entities
that provide pharmacy benefits management services, the
prevalence of electing such different network pricing
arrangements;
(D) pharmacy network design parameters that
encourage enrollees in the plan or coverage to fill
prescriptions at mail order, specialty, or retail
pharmacies that are wholly or partially-owned by that
issuer or entity; and
(E) the degree to which mail order, specialty, or
retail pharmacies that dispense prescription drugs to
an enrollee in a group health plan or health insurance
coverage that are under common ownership (in whole or
part) with group health plans, health insurance
issuers, or entities providing pharmacy benefits
management services or pharmacy benefits administrative
services under group health plan or group or individual
health insurance coverage receive reimbursement that is
greater than the median price charged to the group
health plan or health insurance issuer when the same
drug is dispensed to enrollees in the plan or coverage
by other pharmacies included in the pharmacy network of
that plan, issuer, or entity that are not wholly or
partially owned by the health insurance issuer or
entity providing pharmacy benefits management services.
(2) Requirement.--The Comptroller General of the United
States shall ensure that the report under paragraph (1) does
not contain information that would allow a reader to identify a
specific plan or entity providing pharmacy benefits management
services or otherwise contain commercial or financial
information that is privileged or confidential.
(3) Definitions.--In this subsection, the terms ``group
health plan'', ``health insurance coverage'', and ``health
insurance issuer'' have the meanings given such terms in
section 2791 of the Public Health Service Act (42 U.S.C. 300gg-
91).
SEC. 104. REPORTS ON HEALTH CARE TRANSPARENCY TOOLS AND DATA
REQUIREMENTS.
(a) Initial Report.--Not later than December 31, 2024, the
Comptroller General of the United States shall submit to the Committees
(as defined in subsection (d)) an initial report that--
(1) identifies and describes health care transparency tools
and Federal health care reporting requirements (as described in
subsection (d)) that are in effect as of the date of the
submission of such initial report, including the frequency of
reports with respect to each such requirement and whether any
such requirements are duplicative;
(2) reviews how such reporting requirements are enforced;
(3) analyzes whether the public availability of health care
transparency tools, and the publication of data pursuant to
such reporting requirements, has--
(A) been utilized and valued by consumers,
including reasons for such utilization (or lack
thereof); and
(B) assisted health insurance plan sponsors and
fiduciaries improve benefits, lower health care costs
for plan participants, and meet fiduciary requirements;
(4) includes recommendations to the Committees, the
Secretary of Health and Human Services, the Secretary of Labor,
and the Secretary of the Treasury to--
(A) improve the efficiency, accuracy, and usability
of health care transparency tools;
(B) streamline Federal health care reporting
requirements to eliminate duplicative requirements and
reduce the burden on entities required to submit
reports pursuant to such provisions;
(C) improve the accuracy and efficiency of such
reports while maintaining the integrity and usability
of the data provided by such reports;
(D) address any gaps in data provided by such
reports; and
(E) ensure that the data and information reported
is comparable and usable to consumers, including
patients, plan sponsors, and policy makers.
(b) Final Report.--Not later than December 31, 2028, the
Comptroller General of the United States shall submit to the Committees
a report that includes--
(1) the information provided in the initial report, along
with any updates to such information; and
(2) any new information with respect to health care
transparency tools that have been released following the
submission of such initial report, or new reporting
requirements in effect as of the date of the submission of the
final report.
(c) Report on Expanding Price Transparency Requirements.--Not later
than December 31, 2025, the Comptroller General of the United States,
in consultation with the Secretary of Health and Human Services, health
care provider groups, and patient advocacy groups, shall submit to the
Committees a report that includes recommendations to expand price
transparency reporting requirements to additional care settings, with
an emphasis on settings where shoppable services (as defined in
subsection (d)) are furnished.
(d) Definitions.--In this section:
(1) Committees.--The term ``Committees'' means the
Committee on Ways and Means, the Committee on Energy and
Commerce, and the Committee on Education and the Workforce of
the House of Representatives, and the Committee on Finance and
the Committee on Health, Education, Labor, and Pensions of the
Senate.
(2) Federal health care reporting requirements.--The term
``Federal health care reporting requirements'' includes
regulatory and statutory requirements with respect to the
reporting and publication of health care price, cost access,
and quality data, including requirements established by the
Consolidated Appropriations Act of 2021 (Public Law 116-260),
this Act, and other reporting and publication requirements with
respect to transparency in health care as identified by the
Comptroller General of the United States.
(3) Shoppable service.--The term ``shoppable service''
means a service that can be scheduled by a health care consumer
in advance and includes all ancillary items and services
customarily furnished as part of such service.
SEC. 105. REPORT ON INTEGRATION IN MEDICARE.
(a) Required MA and PDP Reporting.--
(1) MA plans.--Section 1857(e) of the Social Security Act
(42 U.S.C. 1395w-27(e)) is amended by adding at the end the
following new paragraph:
``(6) Required disclosure of certain information relating
to health care provider ownership.--
``(A) In general.--For plan year 2025 and for every
third plan year thereafter, each MA organization
offering an MA plan under this part during such plan
year shall submit to the Secretary, at a time and in a
manner specified by the Secretary--
``(i) the taxpayer identification number
for each health care provider that was a
specified health care provider with respect to
such organization during such year;
``(ii) the total amount of incentive-based
payments made to, and the total amount of
shared losses recoupments collected from, such
specified health care providers during such
plan year; and
``(iii) the total amount of incentive-based
payments made to, and the total amount of
shared losses recoupments collected from,
providers of services and suppliers not
described in clause (ii) during such plan year.
``(B) Definition.--For purposes of this paragraph,
the term `specified health care provider' means, with
respect to an MA organization and a plan year, a
provider of services or supplier with respect to which
such organization (or any person with an ownership or
control interest (as defined in section 1124(a)(3)) in
such organization) is a person with an ownership or
control interest (as so defined).''.
(2) Prescription drug plans.--Section 1860D-12(b) of the
Social Security Act (42 U.S.C. 1395w-112(b)) is amended by
adding at the end the following new paragraph:
``(9) Provision of information relating to pharmacy
ownership.--
``(A) In general.--For plan year 2025 and for every
third plan year thereafter, each PDP sponsor offering a
prescription drug plan under this part during such plan
year shall submit to the Secretary, at a time and in a
manner specified by the Secretary, the taxpayer
identification number and National Provider Identifier
for each pharmacy that was a specified pharmacy with
respect to such sponsor during such year.
``(B) Definition.--For purposes of this paragraph,
the term `specified pharmacy' means, with respect to an
PDP sponsor offering a prescription drug plan and a
plan year, a pharmacy with respect to which--
``(i) such sponsor (or any person with an
ownership or control interest (as defined in
section 1124(a)(3)) in such sponsor) is a
person with an ownership or control interest
(as so defined); or
``(ii) a pharmacy benefit manager offering
services under such plan (or any person with an
ownership or control interest (as so defined)
in such sponsor) is a person with an ownership
or control interest (as so defined).''.
(b) MedPAC Reports.--Part E of title XVIII of the Social Security
Act (42 U.S.C. 1395x et seq.), as amended by section 101, is further
amended by adding at the end the following new section:
``SEC. 1899D. REPORTS ON VERTICAL INTEGRATION UNDER MEDICARE.
``(a) In General.--Not later than June 15, 2029, and every 3 years
thereafter, the Medicare Payment Advisory Commission shall submit to
Congress a report on the state of vertical integration in the health
care sector during the applicable year with respect to entities
participating in the Medicare program, including health care providers,
pharmacies, prescription drug plan sponsors, Medicare Advantage
organizations, and pharmacy benefit managers. Such report shall
include--
``(1) with respect to Medicare Advantage organizations, the
evaluation described in subsection (b);
``(2) with respect to prescription drug plans, pharmacy
benefit managers, and pharmacies, the comparisons and
evaluations described in subsection (c);
``(3) with respect to Medicare Advantage plans under which
benefits are available for physician-administered drugs, the
information described in subsection (d); and
``(4) the identifications described in subsection (e); and
``(5) an analysis of the impact of such integration on
health care access, price, quality, and outcomes.
``(b) Medicare Advantage Organizations.--For purposes of subsection
(a)(1), the evaluation described in this subsection is, with respect to
Medicare Advantage organizations and an applicable year, an evaluation,
taking into account patient acuity and the types of areas serviced by
such organization, of--
``(1) the average number of qualifying diagnoses made
during such year with respect to enrollees of a Medicare
Advantage plan offered by such organization who, during such
year, received a health risk assessment from a specified health
care provider;
``(2) the average risk score for such enrollees who
received such an assessment during such year;
``(3) any relationship between such risk scores for such
enrollees receiving such an assessment from such a provider
during such year and incentive payments made to such providers;
``(4) the average risk score for enrollees of such plan who
received any item or service from a specified health care
provider during such year;
``(5) any relationship between the risk scores of enrollees
under such plan and whether the enrollees have received any
item or service from a specified provider; and
``(6) any relationship between the risk scores of enrollees
under such plan that have received any item or service from a
specified provider and incentive payments made under the plan
to specified providers.
``(c) Prescription Drug Plans.--For purposes of subsection (a)(2),
the comparisons and evaluations described in this subsection are, with
respect to prescription drug plans and an applicable year, the
following:
``(1) For each covered part D drug for which benefits are
available under such a plan, a comparison of the average
negotiated rate in effect with specified pharmacies with such
rates in effect for in-network pharmacies that are not
specified pharmacies.
``(2) Comparisons of the following:
``(A) The total amount paid by pharmacy benefit
managers to specified pharmacies for covered part D
drugs and the total amount so paid to pharmacies that
are not specified pharmacies for such drugs.
``(B) The total amount paid by such sponsors to
specified pharmacy benefit managers as reimbursement
for covered part D drugs and the total amount so paid
to pharmacy benefit managers that are not specified
pharmacy benefit managers as such reimbursement.
``(C) Fees paid under by plan to specified pharmacy
benefit managers compared to such fees paid to pharmacy
benefit managers that are not specified pharmacy
benefit managers.
``(3) An evaluation of the total amount of direct and
indirect remuneration for covered part D drugs passed through
to prescription drug plan sponsors and the total amount
retained by pharmacy benefit managers (including entities under
contract with such a manager).
``(4) To the extent that the available data permits, an
evaluation of fees charged by rebate aggregators that are
affiliated with plan sponsors.
``(d) Physician-Administered Drugs.--For purposes of subsection
(a)(3), the information described in this subsection is, with respect
to physician-administered drugs for which benefits are available under
a Medicare Advantage plan during an applicable year, the following:
``(1) With respect to each such plan, an identification of
each drug for which benefits were available under such plan
only when administered by a health care provider that acquired
such drug from an affiliated pharmacy.
``(2) An evaluation of the difference between the total
number of drugs administered by a health care provider that
were acquired from affiliated pharmacies compared to the number
of such drugs so administered that were acquired from
pharmacies other than affiliated pharmacies, and an evaluation
of the difference in payments for such drugs so administered
when acquired from a specified pharmacy and when acquired from
a pharmacy that is not a specified pharmacy.
``(3) An evaluation of the dollar value of all such drugs
that were not so administered because of a delay attributable
to an affiliated pharmacy compared to the dollar value of all
such drugs that were not so administered because of a delay
attributable to pharmacy that is not an affiliated pharmacy.
``(4) The number of enrollees administered such a drug that
was acquired from an affiliated pharmacy.
``(5) The number of enrollees furnished such a drug that
was acquired from a pharmacy that is not an affiliated
pharmacy.
``(e) Identifications.--For purposes of subsection (a)(4), the
identifications described in this subsection are, with respect to an
applicable year, identifications of each health care entity
participating under the Medicare program with respect to which another
health care entity so participating is a person with an ownership or
control interest (as defined in section 1124(a)(3)).
``(f) Definitions.--In this section:
``(1) Affiliated pharmacy.--The term `affiliated pharmacy'
means, with respect to a Medicare Advantage plan offered by a
Medicare Advantage organization, a pharmacy with respect to
which such organization (or any person with an ownership or
control interest (as defined in section 1124(a)(3)) in such
organization) is a person with an ownership or control interest
(as so defined).
``(2) Applicable year.--The term `applicable year' means,
with respect to a report submitted under subsection (a), the
first calendar year beginning at least 4 years prior to the
date of the submission of such report.
``(3) Covered part d drug.--The term `covered part D drug'
has the meaning given such term in section 1860D-2(e).
``(4) Direct and indirect remuneration.--The term `direct
and indirect remuneration' has the meaning given such term in
section 423.308 of title 42, Code of Federal Regulations (or
any successor regulation).
``(5) Qualifying diagnosis.--The term `qualifying
diagnosis' means, with respect to an enrollee of a Medicare
Advantage plan, a diagnosis that is taken into account in
calculating a risk score for such enrollee under the risk
adjustment methodology established by the Secretary pursuant to
section 1853(a)(3).
``(6) Risk score.--The term `risk score' means, with
respect to an enrollee of a Medicare Advantage plan, the score
calculated for such individual using the methodology described
in paragraph (5).
``(7) Physician-administered drug.--The term `physician-
administered drug' means a drug furnished to an individual
that, had such individual been enrolled under part B and not
enrolled under part C, would have been payable under section
1842(o).
``(8) Specified health care provider.--The term `specified
health care provider' means, with respect to a Medicare
Advantage plan offered by a Medicare Advantage organization, a
health care provider with respect to which such organization
(or any person with an ownership or control interest (as
defined in section 1124(a)(3)) in such organization) is a
person with an ownership or control interest (as so defined).
``(9) Specified pharmacy.--The term `specified pharmacy'
means, with respect to a prescription drug plan offered by a
prescription drug plan sponsor, a pharmacy with respect to
which--
``(A) such sponsor (or any person with an ownership
or control interest (as defined in section 1124(a)(3))
in such sponsor) is a person with an ownership or
control interest (as so defined); or
``(B) a pharmacy benefit manager offering services
under such plan (or any person with an ownership or
control interest (as so defined) in such sponsor) is a
person with an ownership or control interest (as so
defined).
``(10) Specified pharmacy benefit manager.--The term
`specified pharmacy benefit manager' means, with respect to a
prescription drug plan offered by a prescription drug plan
sponsor, a pharmacy benefit manager with respect to which such
sponsor (or any person with an ownership or control interest
(as defined in section 1124(a)(3)) in such sponsor) is a person
with an ownership or control interest (as so defined).''.
TITLE II--FAIR PRICES FOR PATIENTS
SEC. 201. LIMITATION ON COST SHARING TO NET PRICE AMOUNT UNDER MEDICARE
PART D.
(a) In General.--Section 1860D-2 of the Social Security Act (42
U.S.C. 1395w-102) is amended--
(1) in subsection (b)--
(A) in paragraph (2)(A), by striking ``(8) and
(9)'' and inserting ``(8), (9), and (10)'';
(B) in paragraph (9)(B)(ii), by striking ``For a
plan year'' and inserting ``Subject to paragraph (10),
for a plan year''; and
(C) by adding at the end the following new
paragraph:
``(10) Limitation on cost sharing to net price amount.--
``(A) In general.--For a plan year beginning on or
after January 1, 2027, the coverage provides benefits
for a supply of a covered part D drug dispensed by a
pharmacy, for costs in excess of the deductible
specified in paragraph (1) and prior to an individual
reaching the out-of-pocket threshold under paragraph
(4), with cost-sharing for a month's supply that does
not exceed the average net price for such a supply of
such drug during such plan year (or, if lower, the
applicable cash price for such a supply of such drug so
dispensed by such pharmacy).
``(B) Definitions.--In this paragraph:
``(i) Applicable cash price.--The term
`applicable cash price' means, with respect to
a supply of a covered part D drug dispensed by
a pharmacy, the price that such pharmacy would
charge for such supply of such drug dispensed
to an individual without benefits for such drug
under any Federal health care program (as
defined in section 1128B), a group health plan
or group or individual health insurance
coverage (as such terms are defined in section
2791 of the Public Health Service Act), or the
program established under chapter 89 of title
5, United States Code.
``(ii) Average net price.--The term
`average net price' means, with respect to a
supply of a covered part D drug, a prescription
drug plan, and a plan year, the average amount
paid under such plan (including any amounts
paid by an individual enrolled under such plan
as cost sharing for such drug) as payment for
such a supply of such drug dispensed during
such year, less any rebates or other forms of
remuneration received under such plan with
respect to such drug.''; and
(2) in subsection (c), by adding at the end the following
new paragraph:
``(7) Cost sharing limited to net price.--The coverage is
provided in accordance with subsection (b)(10).''.
(b) Conforming Amendment to Cost-Sharing for Low-Income
Individuals.--Section 1860D-14(a)(1)(D)(iii) of the Social Security Act
(42 U.S.C. 1395w-114(a)(1)(D)(iii)) is amended by adding at the end the
following new sentence: ``For plan year 2027 and subsequent plan years,
the copayment amount applicable under this clause to a supply of a
covered part D drug dispensed to the individual may not exceed the
amount provided under section 1860D-2(b)(10).''.
(c) GAO Report.--Not later than January 1, 2029, the Comptroller
General of the United States shall submit to Congress a report
containing--
(1) an analysis of compliance with the amendments made by
this section;
(2) an analysis of enforcement of such amendments;
(3) recommendations with respect to improving such
enforcement; and
(4) recommendations relating to improving public
disclosure, and public awareness of, the requirements of such
amendments.
SEC. 202. REQUIRING A SEPARATE IDENTIFICATION NUMBER AND AN ATTESTATION
FOR EACH OFF-CAMPUS OUTPATIENT DEPARTMENT OF A PROVIDER.
(a) In General.--Section 1833(t) of the Social Security Act (42
U.S.C. 1395l(t)) is amended by adding at the end the following new
paragraph:
``(23) Use of unique health identifiers; attestation.--
``(A) In general.--No payment may be made under
this subsection (or under an applicable payment system
pursuant to paragraph (21)) for items and services
furnished on or after January 1, 2026, by an off-campus
outpatient department of a provider (as defined in
subparagraph (C)) unless--
``(i) such department has obtained, and
such items and services are billed under, a
standard unique health identifier for health
care providers (as described in section
1173(b)) that is separate from such identifier
for such provider; and
``(ii) such provider has submitted to the
Secretary, during the 2-year period ending on
the date such items and services are so
furnished, an attestation that such department
is compliant with the requirements described in
section 413.65 of title 42, Code of Federal
Regulations (or a successor regulation).
``(B) Process for submission and review.--Not later
than 1 year after the date of enactment of this
paragraph, the Secretary shall, through notice and
comment rulemaking, establish a process for each
provider with an off-campus outpatient department of a
provider to submit an attestation pursuant to
subparagraph (A)(ii), and for the Secretary to review
each such attestation and determine, through site
visits, remote audits, or other means (as determined
appropriate by the Secretary), whether such department
is compliant with the requirements described in such
subparagraph.
``(C) Off-campus outpatient department of a
provider defined.--For purposes of this paragraph, the
term `off-campus outpatient department of a provider'
means a department of a provider (as defined in section
413.65 of title 42, Code of Federal Regulations, or any
successor regulation) that is not located--
``(i) on the campus (as defined in such
section) of such provider; or
``(ii) within the distance (described in
such definition of campus) from a remote
location of a hospital facility (as defined in
such section).''.
(b) HHS OIG Analysis.--Not later than January 1, 2030, the
Inspector General of the Department of Health and Human Services shall
submit to Congress--
(1) an analysis of the process established by the Secretary
of Health and Human Services to conduct the reviews and
determinations described in section 1833(t)(23)(B) of the
Social Security Act, as added by subsection (a) of this
section; and
(2) recommendations based on such analysis, as the
Inspector General determines appropriate.
SEC. 203. PARITY IN MEDICARE PAYMENTS FOR HOSPITAL OUTPATIENT
DEPARTMENT SERVICES FURNISHED OFF-CAMPUS.
(a) In General.--Section 1833(t)(16) of the Social Security Act (42
U.S.C. 1395l(t)(16)) is amended by adding at the end the following new
subparagraph:
``(H) Parity in fee schedule amount for certain
services furnished by an off-campus outpatient
department of a provider.--
``(i) In general.--Subject to clause (iii),
in the case of specified OPD services (as
defined in clause (v)) that are furnished
during 2025 or a subsequent year by an off-
campus outpatient department of a provider (as
defined in clause (iv)) (or, in the case of an
off-campus outpatient department of a provider
that is a hospital described in section
1886(d)(1)(B)(v), or is located in a rural area
or a health professional shortage area, such
services that are furnished during 2026 or a
subsequent year), there shall be substituted
for the amount otherwise determined under this
subsection for such service and year an amount
equal to the payment amount that would have
been payable under the applicable payment
system under this part (other than under this
subsection) had such services been furnished by
such a department subject to such payment
system pursuant to paragraph (21)(C).
``(ii) Not budget neutral implementation.--
In making any budget neutrality adjustments
under this subsection for 2025 or a subsequent
year, the Secretary shall not take into account
the reduced expenditures that result from the
application of this subparagraph.
``(iii) Transition.--The Secretary shall
provide for a 4-year phase-in of the
application of clause (i), with clause (i)
being fully applicable for specified OPD
services beginning with 2028 (or in the case of
an off-campus outpatient department of a
provider that is a hospital described in
section 1886(d)(1)(B)(v), or is located in a
rural area or a health professional shortage
area, beginning with 2029).
``(iv) Off-campus department of a
provider.--For purposes of this subparagraph,
the term `off-campus outpatient department of a
provider' means a department of a provider (as
defined in section 413.65(a)(2) of title 42,
Code of Federal Regulations) that is not
located--
``(I) on the campus (as such term
is defined in such section) of such
provider; or
``(II) within the distance
(described in such definition of
campus) from a remote location of a
hospital facility (as defined in such
section).
``(v) Other definitions.--For purposes of
this subparagraph:
``(I) Designated ambulatory payment
classification group.--The term
`designated ambulatory payment
classification group' means an
ambulatory payment classification group
for drug administration services.
``(II) Health professional shortage
area.--The term `health professional
shortage area' has the meaning given
such term in section 332(a)(1)(A) of
the Public Health Service Act.
``(III) Rural area.--The term
`rural area' has the meaning given such
term in section 1886(d)(2)(D).
``(IV) Specified opd services.--The
term `specified OPD services' means
covered OPD services assigned to a
designated ambulatory payment
classification group.''.
(b) Implementation.--Section 1833(t)(12) of the Social Security Act
(42 U.S.C. 1395l(t)(12)) is amended--
(1) in subparagraph (D), by striking ``and'' at the end;
(2) in subparagraph (E), by striking the period at the end
and inserting ``; and''; and
(3) by adding at the end the following new subparagraph:
``(F) the determination of any payment amount under
paragraph (16)(H), including the transition under
clause (iii) of such paragraph.''.
TITLE III--PATIENT-FOCUSED INVESTMENTS
SEC. 301. ESTABLISHING REQUIREMENTS WITH RESPECT TO THE USE OF PRIOR
AUTHORIZATION UNDER MEDICARE ADVANTAGE PLANS.
(a) In General.--Section 1852 of the Social Security Act (42 U.S.C.
1395w-22) is amended by adding at the end the following new subsection:
``(o) Prior Authorization Requirements.--
``(1) In general.--In the case of a Medicare Advantage plan
that imposes any prior authorization requirement with respect
to any applicable item or service (as defined in paragraph (5))
during a plan year, such plan shall--
``(A) beginning with the third plan year beginning
after the date of the enactment of this subsection--
``(i) establish the electronic prior
authorization program described in paragraph
(2); and
``(ii) meet the enrollee protection
standards specified pursuant to paragraph (4);
and
``(B) beginning with the fourth plan year beginning
after the date of the enactment of this subsection,
meet the transparency requirements specified in
paragraph (3).
``(2) Electronic prior authorization program.--
``(A) In general.--For purposes of paragraph
(1)(A), the electronic prior authorization program
described in this paragraph is a program that provides
for the secure electronic transmission of--
``(i) a prior authorization request from a
provider of services or supplier to a Medicare
Advantage plan with respect to an applicable
item or service to be furnished to an
individual and a response, in accordance with
this paragraph, from such plan to such provider
or supplier; and
``(ii) any attachment relating to such
request or response.
``(B) Electronic transmission.--
``(i) Exclusions.--For purposes of this
paragraph, a facsimile, a proprietary payer
portal that does not meet standards specified
by the Secretary, or an electronic form shall
not be treated as an electronic transmission
described in subparagraph (A).
``(ii) Standards.--An electronic
transmission described in subparagraph (A)
shall comply with--
``(I) applicable technical
standards adopted by the Secretary
pursuant to section 1173; and
``(II) other requirements to
promote the standardization and
streamlining of electronic transactions
under this part specified by the
Secretary.
``(iii) Deadline for specification of
additional requirements.--Not later than July
1, 2024, the Secretary shall finalize
requirements described in clause (ii)(II).
``(C) Real-time decisions.--
``(i) In general.--Subject to clause (iv),
the program described in subparagraph (A) shall
provide for real-time decisions (as defined by
the Secretary in accordance with clause (v)) by
a Medicare Advantage plan with respect to prior
authorization requests for applicable items and
services identified by the Secretary pursuant
to clause (ii) if such requests are submitted
with all medical or other documentation
required by such plan.
``(ii) Identification of items and
services.--
``(I) In general.--For purposes of
clause (i), the Secretary shall
identify, not later than the date on
which the initial announcement
described in section 1853(b)(1)(B)(i)
for the third plan year beginning after
the date of the enactment of this
subsection is required to be announced,
applicable items and services for which
prior authorization requests are
routinely approved.
``(II) Updates.--The Secretary
shall consider updating the applicable
items and services identified under
subclause (I) based on the information
described in paragraph (3)(A)(i) (if
available and determined practicable to
utilize by the Secretary) and any other
information determined appropriate by
the Secretary not less frequently than
biennially. The Secretary shall
announce any such update that is to
apply with respect to a plan year not
later than the date on which the
initial announcement described in
section 1853(b)(1)(B)(i) for such plan
year is required to be announced.
``(iii) Request for information.--The
Secretary shall issue a request for information
for purposes of initially identifying
applicable items and services under clause
(ii)(I).
``(iv) Exception for extenuating
circumstances.--In the case of a prior
authorization request submitted to a Medicare
Advantage plan for an individual enrolled in
such plan during a plan year with respect to an
item or service identified by the Secretary
pursuant to clause (ii) for such plan year,
such plan may, in lieu of providing a real-time
decision with respect to such request in
accordance with clause (i), delay such decision
under extenuating circumstances (as specified
by the Secretary), provided that such decision
is provided no later than 72 hours after
receipt of such request (or, in the case that
the provider of services or supplier submitting
such request has indicated that such delay may
seriously jeopardize such individual's life,
health, or ability to regain maximum function,
no later than 24 hours after receipt of such
request).
``(v) Definition of real-time decision.--In
establishing the definition of a real-time
decision for purposes of clause (i), the
Secretary shall take into account current
medical practice, technology, health care
industry standards, and other relevant
information relating to how quickly a Medicare
Advantage plan may provide responses with
respect to prior authorization requests.
``(vi) Implementation.--The Secretary shall
use notice and comment rulemaking for each of
the following:
``(I) Establishing the definition
of a `real-time decision' for purposes
of clause (i).
``(II) Updating such definition.
``(III) Initially identifying
applicable items or services pursuant
to clause (ii)(I).
``(IV) Updating applicable items
and services so identified as described
in clause (ii)(II).
``(3) Transparency requirements.--
``(A) In general.--For purposes of paragraph
(1)(B), the transparency requirements specified in this
paragraph are, with respect to a Medicare Advantage
plan, the following:
``(i) The plan, annually and in a manner
specified by the Secretary, shall submit to the
Secretary the following information:
``(I) A list of all applicable
items and services that were subject to
a prior authorization requirement under
the plan during the previous plan year.
``(II) The percentage and number of
specified requests (as defined in
subparagraph (F)) approved during the
previous plan year by the plan in an
initial determination and the
percentage and number of specified
requests denied during such plan year
by such plan in an initial
determination (both in the aggregate
and categorized by each item and
service).
``(III) The percentage and number
of specified requests submitted during
the previous plan year that were made
with respect to an item or service
identified by the Secretary pursuant to
paragraph (2)(C)(ii) for such plan
year, and the percentage and number of
such requests that were subject to an
exception under paragraph (2)(C)(iv)
(categorized by each item and service).
``(IV) The percentage and number of
specified requests submitted during the
previous plan year that were made with
respect to an item or service
identified by the Secretary pursuant to
paragraph (2)(C)(ii) for such plan year
that were approved (categorized by each
item and service).
``(V) The percentage and number of
specified requests that were denied
during the previous plan year by the
plan in an initial determination and
that were subsequently appealed.
``(VI) The number of appeals of
specified requests resolved during the
preceding plan year, and the percentage
and number of such resolved appeals
that resulted in approval of the
furnishing of the item or service that
was the subject of such request,
categorized by each applicable item and
service and categorized by each level
of appeal (including judicial review).
``(VII) The percentage and number
of specified requests that were denied,
and the percentage and number of
specified requests that were approved,
by the plan during the previous plan
year through the utilization of
decision support technology, artificial
intelligence technology, machine-
learning technology, clinical decision-
making technology, or any other
technology specified by the Secretary.
``(VIII) The average and the median
amount of time (in hours) that elapsed
during the previous plan year between
the submission of a specified request
to the plan and a determination by the
plan with respect to such request for
each such item and service, excluding
any such requests that were not
submitted with the medical or other
documentation required to be submitted
by the plan.
``(IX) The percentage and number of
specified requests that were excluded
from the calculation described in
subclause (VIII) based on the plan's
determination that such requests were
not submitted with the medical or other
documentation required to be submitted
by the plan.
``(X) Information on each
occurrence during the previous plan
year in which, during a surgical or
medical procedure involving the
furnishing of an applicable item or
service with respect to which such plan
had approved a prior authorization
request, the provider of services or
supplier furnishing such item or
service determined that a different or
additional item or service was
medically necessary, including a
specification of whether such plan
subsequently approved the furnishing of
such different or additional item or
service.
``(XI) A disclosure and description
of any technology described in
subclause (VII) that the plan utilized
during the previous plan year in making
determinations with respect to
specified requests.
``(XII) The number of grievances
(as described in subsection (f))
received by such plan during the
previous plan year that were related to
a prior authorization requirement.
``(XIII) Such other information as
the Secretary determines appropriate.
``(ii) The plan shall provide--
``(I) to each provider or supplier
who seeks to enter into a contract with
such plan to furnish applicable items
and services under such plan, the list
described in clause (i)(I) and any
policies or procedures used by the plan
for making determinations with respect
to prior authorization requests;
``(II) to each such provider and
supplier that enters into such a
contract, access to the criteria used
by the plan for making such
determinations and an itemization of
the medical or other documentation
required to be submitted by a provider
or supplier with respect to such a
request; and
``(III) to an enrollee of the plan,
upon request, access to the criteria
used by the plan for making
determinations with respect to prior
authorization requests for an item or
service.
``(B) Option for plan to provide certain additional
information.--As part of the information described in
subparagraph (A)(i) provided to the Secretary during a
plan year, a Medicare Advantage plan may elect to
include information regarding the percentage and number
of specified requests made with respect to an
individual and an item or service that were denied by
the plan during the preceding plan year in an initial
determination based on such requests failing to
demonstrate that such individuals met the clinical
criteria established by such plan to receive such items
or services.
``(C) Regulations.--The Secretary shall, through
notice and comment rulemaking, establish requirements
for Medicare Advantage plans regarding the provision
of--
``(i) access to criteria described in
subparagraph (A)(ii)(II) to providers of
services and suppliers in accordance with such
subparagraph; and
``(ii) access to such criteria to enrollees
in accordance with subparagraph (A)(ii)(III).
``(D) Publication of information.--The Secretary
shall publish information described in subparagraph
(A)(i) and subparagraph (B) on a public website of the
Centers for Medicare & Medicaid Services. Such
information shall be so published on an individual plan
level and may in addition be aggregated in such manner
as determined appropriate by the Secretary.
``(E) Medpac report.--Not later than 3 years after
the date information is first submitted under
subparagraph (A)(i), the Medicare Payment Advisory
Commission shall submit to Congress a report on such
information that includes a descriptive analysis of the
use of prior authorization. As appropriate, the
Commission should report on statistics including the
frequency of appeals and overturned decisions. The
Commission shall provide recommendations, as
appropriate, on any improvement that should be made to
the electronic prior authorization programs of Medicare
Advantage plans.
``(F) Specified request defined.--For purposes of
this paragraph, the term `specified request' means a
prior authorization request made with respect to an
applicable item or service.
``(4) Enrollee protection standards.--For purposes of
paragraph (1)(A)(ii), with respect to the use of prior
authorization by Medicare Advantage plans for applicable items
and services, the enrollee protection standards specified in
this paragraph are--
``(A) the adoption of transparent prior
authorization programs developed in consultation with
enrollees and with providers and suppliers with
contracts in effect with such plans for furnishing such
items and services under such plans;
``(B) allowing for the waiver or modification of
prior authorization requirements based on the
performance of such providers and suppliers in
demonstrating compliance with such requirements, such
as adherence to evidence-based medical guidelines and
other quality criteria; and
``(C) conducting annual reviews of such items and
services for which prior authorization requirements are
imposed under such plans through a process that takes
into account input from enrollees and from providers
and suppliers with such contracts in effect and is
based on consideration of prior authorization data from
previous plan years and analyses of current coverage
criteria.
``(5) Applicable item or service defined.--For purposes of
this subsection, the term `applicable item or service' means,
with respect to a Medicare Advantage plan, any item or service
for which benefits are available under such plan, other than a
covered part D drug.
``(6) Reports to congress.--
``(A) GAO.--Not later than the end of the fourth
plan year beginning on or after the date of the
enactment of this subsection, the Comptroller General
of the United States shall submit to Congress a report
containing an evaluation of the implementation of the
requirements of this subsection and an analysis of
issues in implementing such requirements faced by
Medicare Advantage plans.
``(B) HHS.--Not later than the end of the fifth
plan year beginning after the date of the enactment of
this subsection, and biennially thereafter through the
date that is 10 years after such date of enactment, the
Secretary shall submit to Congress a report containing
a description of the information submitted under
paragraph (3)(A)(i) during--
``(i) in the case of the first such report,
the fourth plan year beginning after the date
of the enactment of this subsection; and
``(ii) in the case of a subsequent report,
the 2 plan years preceding the year of the
submission of such report.''.
(b) Ensuring Timely Responses for All Prior Authorization Requests
Submitted Under Part C.--Section 1852(g) of the Social Security Act (42
U.S.C. 1395w-22(g)) is amended--
(1) in paragraph (1)(A), by inserting ``and in accordance
with paragraph (6)'' after ``paragraph (3)'';
(2) in paragraph (3)(B)(iii), by inserting ``(or, subject
to subsection (o), with respect to prior authorization requests
submitted on or after the first day of the third plan year
beginning after the date of the enactment of the [Improving
Seniors' Timely Access to Care Act of 2023], not later than 24
hours)'' after ``72 hours''.
(3) by adding at the end the following new paragraph:
``(6) Timeframe for response to prior authorization
requests.--Subject to paragraph (3) and subsection (o), in the
case of an organization determination made with respect to a
prior authorization request for an item or service to be
furnished to an individual submitted on or after the first day
of the third plan year beginning after the date of the
enactment of this paragraph, the organization shall notify the
enrollee (and the physician involved, as appropriate) of such
determination no later than 7 days (or such shorter timeframe
as the Secretary may specify through notice and comment
rulemaking, taking into account enrollee and stakeholder
feedback) after receipt of such request.''.
(c) Rule of Construction.--None of the amendments made by this
section may be construed to affect the finalization of the proposed
rule entitled ``Medicare and Medicaid Programs; Patient Protection and
Affordable Care Act; Advancing Interoperability and Improving Prior
Authorization Processes for Medicare Advantage Organizations, Medicaid
Managed Care Plans, State Medicaid Agencies, Children's Health
Insurance Program (CHIP) Agencies and CHIP Managed Care Entities,
Issuers of Qualified Health Plans on the Federally Facilitated
Exchanges, Merit-Based Incentive Payment System (MIPS) Eligible
Clinicians, and Eligible Hospitals and Critical Access Hospitals in the
Medicare Promoting Interoperability Program'' published on December 13,
2022 (87 Fed. Reg. 76238), or application of such rule so finalized,
for plan years before the third plan year beginning on or after the
date of the enactment of this Act.
SEC. 302. EXTENSION OF CERTAIN DIRECT SPENDING REDUCTIONS.
Section 251A(6)(D) of the Balanced Budget and Emergency Deficit
Control Act of 1985 (901a(6)(D)) is amended--
(1) in clause (i), by striking ``; and'' and inserting a
semicolon;
(2) in clause (ii), by striking ``second 6 months in which
such order is effective for such fiscal year, the payment
reduction shall be 0 percent.'' and inserting ``2 month period
beginning on the day after the last day of the period described
in clause (i) in which such order is effective for such fiscal
year, the payment reduction shall be 1.5 percent; and''; and
(3) by adding at the end the following new clause:
``(iii) with respect to the last 4 months
in which such order is effective for such
fiscal year, the payment reduction shall be 0
percent.''.
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