[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4905 Introduced in House (IH)]
<DOC>
118th CONGRESS
1st Session
H. R. 4905
To amend the Internal Revenue Code of 1986, the Public Health Service
Act, and the Employee Retirement Income Security Act of 1974 to promote
group health plan price transparency.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 26, 2023
Mr. Fitzpatrick (for himself and Ms. Lee of Nevada) introduced the
following bill; which was referred to the Committee on Energy and
Commerce, and in addition to the Committees on Education and the
Workforce, and Ways and Means, 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 amend the Internal Revenue Code of 1986, the Public Health Service
Act, and the Employee Retirement Income Security Act of 1974 to promote
group health plan price transparency.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Health Insurance Price Transparency
Act of 2023''.
SEC. 2. 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 this
section, 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 this
section, each group health plan (other than a grandfathered
health plan (as defined in section 1251(e) of the Patient
Protection and Affordable Care Act (42 U.S.C. 18011(e))) 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 paragraph:
``(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 this
section, 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 this
section, each group health plan (other than a grandfathered
health plan (as defined in section 1251(e) of the Patient
Protection and Affordable Care Act (42 U.S.C. 18011(e))) 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 paragraph:
``(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 this
section, 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 this
section, each group health plan (other than a grandfathered
health plan (as defined in section 1251(e) of the Patient
Protection and Affordable Care Act (42 U.S.C. 18011(e))) 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 paragraph:
``(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.''.
(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.
<all>