To ensure health care consumer and provider access to certain health benefits plan information and to amend title XIX of the Social Security Act to provide transparency in hospital price and quality information.

Summary: Patients' Right to Know Act - Requires each entity offering a health benefits plan to make available to enrollees and potential enrollees specified information, including covered items and services, a list of limitations and restrictions, the claims appeal process, out-of-pocket cost-sharing, among other things.

Amends title XIX (Medicaid) of the Social Security Act to require the state Medicaid plan to provide that the state will establish and maintain laws to require disclosure to the public and the Secretary of information on hospital and ambulatory surgical center prices and quality.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Patients' Right to Know Act''.

SEC. 2. HEALTH BENEFITS PLAN INFORMATION TRANSPARENCY.

    (a) Ensuring Consumer and Provider Access to Health Benefits Plan 
Information.--
            (1) In general.--Each entity offering a health benefits 
        plan (as defined in subsection (d)) shall make available to 
        enrollees and potential enrollees of such plan the following 
        information:
                    (A) The items and services that are included as 
                part of the coverage offered by such plan and the items 
                and services that are not so included.
                    (B) An explicit and clear list of limitations and 
                restrictions in the health insurance coverage offered, 
                along with a description of such limitations and 
                restrictions.
                    (C) A description of the process available for 
                appealing coverage decisions made by such plan.
                    (D) The number of appeals related to coverage 
                decisions made during the previous calendar year and 
                the outcomes of such appeals.
                    (E) The amount of cost-sharing (including premiums, 
                deductibles, copayments, co-insurance, maximum possible 
                annual out-of-pocket expenditure, and maximum possible 
                lifetime out-of-pocket expenditure) required by such 
                plan.
                    (F) The number of participating providers according 
                to medical specialty type.
                    (G) The extent to which a particular health care 
                provider accepts coverage provided by such plan and the 
                extent to which such a provider participates in the 
                provider network of such plan.
                    (H) The percentage of total expenditures made by 
                such plan during the previous calendar year that are 
                attributable to administrative costs and an explanation 
                of all the assumptions and factors used to calculate 
                such percentage.
                    (I) The plan terms and conditions, claims payment 
                policies and practices, periodic financial disclosure, 
                data on enrollment and disenrollment, data on the 
                number of claims denials, data on rating practices, 
                information on cost-sharing and payments with respect 
                to in-network and out-of-network coverage, and any 
                other information determined by the Secretary of Health 
                and Human Services to be beneficial to consumers or 
                medical providers.
                    (J) Information the Secretary of Health and Human 
                Services deems appropriate regarding the amount of 
                waste and fraud in the operations of such plan, efforts 
                to address such waste and fraud, and the outcomes of 
                such efforts.
        The requirement under this paragraph (including subparagraph 
        (H)) shall apply only to entities offering health benefits 
        plans (as defined in subsection (d)).
            (2) Out-of-pocket cost-sharing transparency.--
                    (A) In general.--An entity offering a health 
                benefits plan shall disclose, upon request of an 
                enrollee of such plan, the amount of out-of-pocket 
                cost-sharing (including deductibles, copayments, and 
                coinsurance) under such plan that the enrollee would be 
                responsible for paying with respect to the furnishing 
                of a specific item or service by a provider 
                participating in such plan in a timely manner. At a 
                minimum, such information shall be made available to 
                the enrollee, upon request, prior to seeking care, and 
                shall be provided in a manner that allows such enrollee 
                to compare providers based on such information.
                    (B) Health care quality information to be 
                disclosed.--In disclosing information described in 
                subparagraph (A), an entity offering a health benefits 
                plan shall, to the extent practicable and appropriate, 
                associate such information with any available risk-
                adjusted quality data measures. The Secretary may 
                specify that such measures include those that have been 
                endorsed by the National Quality Forum.
            (3) Advance notice of plan changes.--An entity offering a 
        health benefits plan shall not make a change to such plan 
        without reasonable and timely advance notice of such change to 
        enrollees of such plan.
            (4) Contracting reimbursement transparency.--An entity 
        offering a health benefits plan shall disclose to each health 
        care provider information relating to the reimbursement 
        arrangements between such plan and such provider.
    (b) Administrative Provisions and Information Design.--
            (1) Timely disclosure and updates; additional information 
        disclosures.--
                    (A) Timely disclosure and updates.--Each entity 
                offering a health benefits plan shall provide for 
                timely access to information described in subsection 
                (a) and consistent with such subsection, including 
                through an Internet website. Such information shall 
                first be made available not later than 18 months after 
                the date of the enactment of this Act. Such information 
                shall be updated as often as is deemed feasible by the 
                Secretary of Health and Human Services, but not less 
                than once a calendar quarter.
                    (B) Additional information disclosures.--The 
                Secretary may undertake rulemaking as necessary in 
                order to ensure that additional information, as 
                specified by the Secretary, is progressively made 
                available by entities offering health benefits plans, 
                in order to provide for the maximum feasible reporting 
                of information to meet the needs of consumers and 
                providers of health care in making determinations with 
                regard to health care items, insurance, and services. 
                In no case shall such additional information be 
                required to be made available by any entity other than 
                an entity offering a health benefits plan (as defined 
                in subsection (d)).
            (2) Information design.--
                    (A) In general.--Each entity offering a health 
                benefits plan shall ensure that the information 
                described in paragraph (1) is made available in a 
                manner that--
                            (i) is in a format that is easily 
                        accessible, useable, and understandable to 
                        enrollees and potential enrollees of the plan 
                        as well as health care providers as applicable;
                            (ii) uses language that the intended 
                        audience can readily understand and that is 
                        clean, concise, well-organized, and follows 
                        other best practices of language writing; and
                            (iii) to the greatest extent feasible, 
                        permits an individual to search the information 
                        by a user-defined geographic area, such as 
                        within a 50-mile radius of the user's home 
                        address.
                    (B) Enabling consumers to compare information.--The 
                Secretary of Health and Human Services shall, by final 
                rule issued not later than 12 months after the date of 
                the enactment of this Act, require entities offering 
                health benefits plans to disclose the information 
                described in subsection (a)(1) in such a format as to 
                allow individuals to compare the coverage options 
                available to them in as uniform a manner as possible.
    (c) Penalty.--The Secretary shall provide for a methodology to 
impose a penalty fee against each entity offering a health benefits 
plan that fails to substantially meet the requirements of subsections 
(a) and (b). Such methodology shall--
            (1) provide for an increased penalty amount in the case of 
        such an entity that knowingly misrepresents information 
        required to be disclosed under subsection (a) or under 
        regulations issued pursuant to subsection (b)(1)(B);
            (2) vary the amount of such fee based on the size of the 
        entity involved and type of infraction.
The provisions of section 1128A (other than subsections (a) and (b)) 
shall apply to a penalty fee imposed under this subsection in the same 
manner as such provisions apply to a penalty or proceeding under 
section 1128A(a).
    (d) Entity Offering a Health Benefits Plan Defined.--For the 
purposes of this section, the term ``entity offering a health benefits 
plan'' means a health insurance issuer with respect to the offering of 
health insurance coverage, including in the individual market and small 
and large group market (as such terms are defined in section 2791 of 
the Public Health Service Act); a plan sponsor with respect to the 
offering of a group health plan (as defined in such section 2791); and 
entities responsible for the administration of governmental health 
plans (including the Centers for Medicare & Medicaid Services with 
respect to the Medicare program under title XVIII of the Social 
Security Act, State agencies responsible for administration of State 
plans under the Medicaid program under title XIX of such Act or State 
child assistance plans under the State Children's Health Insurance 
Program under title XXI of such Act, and the Office of Personnel 
Management with respect to the Federal Employees Health Benefits 
Program under chapter 89 of title 5, United States Code).

SEC. 3. HOSPITAL AND AMBULATORY SURGICAL CENTER PRICE AND QUALITY 
              TRANSPARENCY.

    (a) In General.--Section 1902(a) of the Social Security Act (42 
U.S.C. 1396a(a)) is amended--
            (1) by striking ``and'' at the end of paragraph (72);
            (2) by striking the period at the end of paragraph (73) and 
        inserting ``; and'';
            (3) by inserting after paragraph (73) the following new 
        paragraph:
            ``(74) provide that the State will establish and maintain 
        laws, in accordance with the requirements of section 1921A, to 
        require disclosure of information on hospital and ambulatory 
        surgical center charges and quality, to make such information 
        available to the public and the Secretary.''; and
            (4) by inserting after section 1921 the following new 
        section:

``SEC. 1921A. PRICE AND QUALITY TRANSPARENCY.

    ``(a) In General.--The requirements referred to in section 
1902(a)(74) are that the laws of a State must--
            ``(1) require reporting to a State (or its agent) by each 
        hospital located therein, of information on--
                    ``(A) the charges for inpatient and outpatient 
                services typically performed (as defined by the 
                Secretary through notice and comment rulemaking) by 
                such hospital;
                    ``(B) the reimbursement amount under title XVIII 
                and under the State plan under this title for such 
                services; and
                    ``(C) if the hospital allows for or provides 
                reduced charges for individuals based on financial 
                need, the factors considered in making determinations 
                for reductions in charges, including any formula for 
                such determination and the contact information for the 
                specific department of a hospital that responds to such 
                inquiries;
            ``(2) provide for notice to individuals seeking or 
        requiring such services of the availability of information on 
        charges described in paragraph (1);
            ``(3) provide for timely access to such information, 
        including at least through an Internet website, by individuals 
        seeking or requiring such services; and
            ``(4) provide for timely access to information regarding 
        the quality of care at each hospital made publicly available in 
        accordance with section 501 of the Medicare Prescription Drug, 
        Improvement, and Modernization Act of 2003, section 1139A, or 
        section 1139B.
    ``(b) Application to Ambulatory Surgical Centers.--The requirements 
described in subsection (a) shall apply, to the greatest extent 
practicable, to ambulatory surgical centers in the same manner as such 
requirements apply to hospitals, except that in applying paragraph (4) 
of such subsection, the references described in such paragraph shall be 
deemed to be a reference to section 1833(i)(7).
    ``(c) Consultation With Stakeholders.--For purposes of carrying out 
this section, the Secretary shall consult with appropriate stakeholders 
through a formal process to obtain guidance prior to issuing any 
implementing policies.
    ``(d) Hospital Defined.--For the purposes of this section, the term 
`hospital' means an institution that meets the requirements of 
paragraphs (1) and (7) of section 1861(e) and includes an institution 
to which section 1820(c) applies.
    ``(e) Ambulatory Surgical Center Defined.--For purposes of this 
section, the term `ambulatory surgical center' means a center described 
in section 1832(a)(2)(F)(i).''
    (b) Effective Date.--
            (1) In general.--The amendments made by subsection (a) 
        shall apply to State plans beginning not later than 2 years 
        after the date of the enactment of this Act.
            (2) Existing programs.--The Secretary of Health and Human 
        Services shall establish a process by which a State with an 
        existing program may certify to the Secretary that its program 
        satisfies the requirements of section 1921A of the Social 
        Security Act, as inserted by subsection (a).