```

[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 3548 Introduced in Senate (IS)]

<DOC>

118th CONGRESS
  1st Session
                                S. 3548

  To amend the Public Health Service Act to provide for hospital and 
                      insurer price transparency.

_______________________________________________________________________

                   IN THE SENATE OF THE UNITED STATES

                           December 14, 2023

 Mr. Braun (for himself, Mr. Sanders, Ms. Smith, and Mr. Hickenlooper) 
introduced the following bill; which was read twice and referred to the 
          Committee on Health, Education, Labor, and Pensions

_______________________________________________________________________

                                 A BILL

 
  To amend the Public Health Service Act to provide for hospital and 
                      insurer 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 Care Prices Revealed and 
Information to Consumers Explained Transparency Act'' or the ``Health 
Care PRICE Transparency Act 2.0''.

SEC. 2. STRENGTHENING HOSPITAL PRICE TRANSPARENCY REQUIREMENTS.

    (a) In General.--Section 2718(e) of the Public Health Service Act 
(42 U.S.C. 300gg-18(e)) is amended to read as follows:
    ``(e) Standard Hospital Charges.--
            ``(1) In general.--
                    ``(A) Disclosure of standard charges.--For purposes 
                of paragraph (1), the price transparency requirement 
                described in this paragraph is, with respect to a 
                hospital, that such hospital, in accordance with a 
                method and format established by the Secretary under 
                subparagraph (C), compile and make public (without 
                subscription and free of charge) for each month--
                            ``(i) all 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 through December 31, 
                                2024, after which the hospital's prices 
                                shall include all 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) Standard charges described.--For purposes of 
                subparagraph (A), the information described in this 
                subparagraph is, with respect to standard charges and 
                prices, as applicable, made public by a hospital, the 
                following:
                            ``(i) A plain language description of each 
                        item or service, accompanied by any applicable 
                        billing codes, including modifiers, using 
                        commonly recognized billing code sets, 
                        including the Current Procedural Terminology 
                        code, the Healthcare Common Procedure Coding 
                        System code, the diagnosis-related group, the 
                        National Drug Code, and other nationally 
                        recognized identifier.
                            ``(ii) The gross charge, as applicable, 
                        expressed as a dollar amount, for each such 
                        item or service, when provided in, as 
                        applicable, the inpatient setting and 
                        outpatient department setting.
                            ``(iii) The discounted cash price, as 
                        applicable, expressed as a dollar amount, for 
                        each such item or service when provided in, as 
                        applicable, the inpatient setting and 
                        outpatient department setting (or, in the case 
                        no discounted cash price is available for an 
                        item or service, the minimum cash price 
                        accepted by the hospital from self-pay 
                        individuals for such item or service, expressed 
                        as a dollar amount, as well as, with respect to 
                        prices made public pursuant to subparagraph 
                        (A)(ii), a link to a consumer-friendly document 
                        that clearly explains the hospital's charity 
                        care policy). The hospital shall accept the 
                        discounted cash price as payment in full from 
                        any patient that chooses to pay in cash without 
                        regard to the patient's coverage.
                            ``(iv) The payer-specific negotiated 
                        charges, expressed as a dollar amount and 
                        clearly associated with the name of the 
                        applicable third party payer and name of each 
                        plan, that apply to each such item or service 
                        when provided in, as applicable, the inpatient 
                        setting and outpatient department setting. If 
                        the charges are based on an algorithm, 
                        percentage of another amount, or other formula 
                        or criteria, the hospital also shall disclose 
                        such algorithm, percentage, formula, or 
                        criteria as set forth in its contract and any 
                        other terms, schedules, exhibits, data, or 
                        other information referenced in any such 
                        contract as shall be required to determine and 
                        disclose the negotiated charge.
                            ``(v) The de-identified maximum and minimum 
                        negotiated charges, as applicable, for each 
                        such item or service, expressed as a non-zero 
                        dollar amount.
                            ``(vi) Any other additional information the 
                        Secretary may require for the purpose of 
                        improving the accuracy of, or enabling 
                        consumers to easily understand and compare, 
                        standard charges and prices for an item or 
                        service, except information that is duplicative 
                        of any other reporting requirement under this 
                        subsection. In the case of standard charges and 
                        prices for an item or service included as part 
                        of a bundled, per diem, episodic, or other 
                        similar arrangement, the information described 
                        in this subparagraph shall be made available as 
                        determined appropriate by the Secretary.
                    ``(C) Uniform method and format.--Not later than 
                January 1, 2025, the Secretary shall establish a 
                standard, uniform method and format for hospitals to 
                use in compiling and making public standard charges 
                pursuant to subparagraph (A)(i) and a standard, uniform 
                method and format for such hospitals to use in 
                compiling and making public prices pursuant to 
                subparagraph (A)(ii). Such methods and formats--
                            ``(i) shall, in the case of such method and 
                        format for making public standard charges 
                        pursuant to subparagraph (A)(i), ensure that 
                        such charges are made available in a machine-
                        readable spreadsheet format;
                            ``(ii) may be similar to any template made 
                        available by the Centers for Medicare & 
                        Medicaid Services as of the date of the 
                        enactment of this subparagraph;
                            ``(iii) shall meet such standards as 
                        determined appropriate by the Secretary in 
                        order to ensure the accessibility and usability 
                        of such charges and prices; and
                            ``(iv) shall be updated as determined 
                        appropriate by the Secretary, in consultation 
                        with stakeholders.
            ``(2) No deemed compliance.--The availability of a price 
        estimator tool shall not be considered to deem compliance with 
        or otherwise vitiate the requirements of paragraph (2)(A)(ii) 
        or any other requirements of this section. Furthermore, the use 
        of an estimator tool shall not be used for purposes of 
        compliance with any provisions in this Section.
            ``(3) Monitoring compliance.--The Secretary shall, in 
        consultation with the Inspector General of the Department of 
        Health and Human Services, establish a process to monitor 
        compliance with this subsection. Such process shall ensure that 
        each hospital's compliance with this subsection is reviewed not 
        less frequently than once every year.
            ``(4) Attestation.--A senior official from each hospital 
        (the Chief Executive Officer, Chief Financial Officer, or an 
        official of equivalent seniority) shall attest to the accuracy 
        and completeness of the disclosures made in accordance with the 
        hospital price transparency requirements set forth in this 
        regulation. Such attestation shall be deemed to be material to 
        payment from the Federal Government to the hospital.
            ``(5) Enforcement.--
                    ``(A) In general.--In the case of a hospital that 
                fails to comply with the requirements of this 
                subsection, not later than 30 days after the date on 
                which the Secretary determines such failure exists, the 
                Secretary shall submit to such hospital a notification 
                of such determination, which shall include a request 
                for 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 hospital that 
                        has received a request for a corrective action 
                        plan under subparagraph (A) and fails to comply 
                        with the requirements of this subsection by the 
                        date that is 45 days after such request is made 
                        shall be subject to a civil monetary penalty of 
                        an amount specified by the Secretary for each 
                        day (beginning with the day on which the 
                        Secretary first determined that such hospital 
                        was not complying with such requirements) 
                        during which such failure was ongoing. Such 
                        amount shall not exceed--
                                    ``(I) in the case of a hospital 
                                with 30 or fewer beds, $300 per day;
                                    ``(II) in the case of a hospital 
                                with more than 30 beds but fewer than 
                                101 beds, $10 per bed per day (or, in 
                                the case of such a hospital that has 
                                been noncompliant with such 
                                requirements for a 1-year period or 
                                longer, beginning with the first day 
                                following such 1-year period, $12.50 
                                per bed per day);
                                    ``(III) in the case of a hospital 
                                with more than 100 beds but fewer than 
                                301 beds, $15 per bed per day (or, in 
                                the case of such a hospital that has 
                                been noncompliant with such 
                                requirements for a 1-year period or 
                                longer, beginning with the first day 
                                following such 1-year period, $17.50 
                                per bed per day);
                                    ``(IV) in the case of a hospital 
                                with more than 300 beds but fewer than 
                                501 beds, $20 per bed per day (or, in 
                                the case of such a hospital that has 
                                been noncompliant with such 
                                requirements for a 1-year period or 
                                longer, beginning with the first day 
                                following such 1-year period, $25 per 
                                bed per day); and
                                    ``(V) in the case of a hospital 
                                with more than 500 beds, $25 per bed 
                                per day (or, in the case of such a 
                                hospital that has been noncompliant 
                                with such requirements for a 1-year 
                                period or longer, beginning with the 
                                first day following such 1-year period, 
                                $35 per bed per day).
                            ``(ii) Increase authority.--In applying 
                        this subparagraph with respect to violations 
                        occurring in 2027 or a subsequent year, the 
                        Secretary may through notice and comment 
                        rulemaking increase--
                                    ``(I) the limitation on the per day 
                                amount of any penalty applicable to a 
                                hospital under clause (i)(I);
                                    ``(II) the limitations on the per 
                                bed per day amount of any penalty 
                                applicable under any of subclauses (II) 
                                through (V) of clause (i); and
                                    ``(III) the limitation on the 
                                increase of any penalty applied under 
                                clause (iii) pursuant to the amounts 
                                specified in subclause (II) of such 
                                clause.
                            ``(iii) Persistent noncompliance.--
                                    ``(I) In general.--In the case of a 
                                hospital that the Secretary has 
                                determined to be knowingly and 
                                willfully noncompliant with the 
                                provisions of this subsection two or 
                                more times during a 1-year period, the 
                                Secretary may increase any penalty 
                                otherwise applicable under this 
                                subparagraph by the amount specified in 
                                subclause (II) with respect to such 
                                hospital and may require such hospital 
                                to complete such additional corrective 
                                actions plans as the Secretary may 
                                specify.
                                    ``(II) Specified amount.--For 
                                purposes of subclause (I), the amount 
                                specified in this subclause is, with 
                                respect to a hospital--
                                            ``(aa) with more than 30 
                                        beds but fewer than 101 beds, 
                                        an amount that is not less than 
                                        $500,000 and not more than 
                                        $1,000,000;
                                            ``(bb) with more than 100 
                                        beds but fewer than 301 beds, 
                                        an amount that is greater than 
                                        $1,000,000 and not more than 
                                        $2,000,000;
                                            ``(cc) with more than 300 
                                        beds but fewer than 501 beds, 
                                        an amount that is greater than 
                                        $2,000,000 and not more than 
                                        $4,000,000; and
                                            ``(dd) with more than 500 
                                        beds, and amount that is not 
                                        less than $5,000,000 and not 
                                        more than $10,000,000.
                            ``(iv) Provision of technical assistance.--
                        The Secretary may, to the extent practicable, 
                        provide technical assistance relating to 
                        compliance with the provisions of this section 
                        to hospitals requesting such assistance.
                            ``(v) 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.
                    ``(C) No waiver.--The Secretary shall not grant or 
                extend any waiver, delay, tolling, or other mitigation 
                of a civil monetary penalty for violation of this 
                subsection.
            ``(6) Definitions.--For purposes of this subsection:
                    ``(A) Discounted cash price.--The term `discounted 
                cash price' means the minimum charge that the hospital 
                accepts from an individual who pays cash, or cash 
                equivalent, for a hospital-furnished item or service.
                    ``(B) Gross charge.--The term `gross charge' means 
                the charge for an individual item or service that is 
                reflected on a hospital's chargemaster, absent any 
                discounts.
                    ``(C) Hospital.--The term `hospital' means a 
                hospital (as defined in section 1861(e) of the Social 
                Security Act), a critical access hospital (as defined 
                in section 1861(mmm)(1) of the Social Security Act), or 
                a rural emergency hospital (as defined in section 
                1861(kkk) of the Social Security Act), together with 
                any parent, subsidiary, or other affiliated provider or 
                supplier of health care items and services without 
                regard to whether such parent, subsidiary, or other 
                affiliated provider or supplier operates under separate 
                licensure, certification, or designation.
                    ``(D) Payer-specific negotiated charge.--The term 
                `payer-specific negotiated charge' means the charge 
                that a hospital has negotiated with a third party payer 
                for an item or service.
                    ``(E) Shoppable service.--The term `shoppable 
                service' means a service that can be scheduled by a 
                health care consumer in advance and includes all 
                ancillary items and services customarily furnished as 
                part of such service.
                    ``(F) Third party payer.--The term `third party 
                payer' means an entity that is, by statute, contract, 
                or agreement, legally responsible for payment of a 
                claim for a health care item or service.''.
    (b) Effective Date.--
            (1) In general.--The amendments made by subsection (a) 
        shall apply beginning January 1, 2025.
            (2) Continued applicability of rules for previous years.--
        Nothing in the amendments made by this section may be construed 
        as affecting the applicability of the regulations codified at 
        part 180 of title 45, Code of Federal Regulations, before 
        January 1, 2025.
    (c) Continued Applicability of State Law.--The provisions of this 
Act shall not supersede any provision of State law that establishes, 
implements, or continues in effect any requirement or prohibition 
related to health care price transparency, except to the extent that 
such requirement or prohibition prevents the application of a 
requirement or prohibition of this Act.

SEC. 3. INCREASING PRICE TRANSPARENCY OF CLINICAL DIAGNOSTIC LABORATORY 
              TESTS UNDER THE MEDICARE PROGRAM.

    Section 2718 of the Public Health Service Act (42 U.S.C. 300gg-18) 
is amended by adding at the end the following:
    ``(f) Clinical Diagnostic Laboratory Price Transparency.--
            ``(1) In general.--Beginning January 1, 2025, any 
        applicable laboratory that receives payment from a group health 
        plan or health insurance issuer for furnishing any specified 
        clinical diagnostic laboratory test shall--
                    ``(A) make publicly available on an internet 
                website the information described in paragraph (2) with 
                respect to each such specified clinical diagnostic 
                laboratory test that such laboratory so furnishes; and
                    ``(B) ensure that such information is updated not 
                less frequently than annually.
            ``(2) Information described.--For purposes of paragraph 
        (1), the information described in this paragraph is, with 
        respect to an applicable laboratory and a specified clinical 
        diagnostic laboratory test, the following:
                    ``(A) A plain language description of each item or 
                service, accompanied by any applicable billing codes, 
                including modifiers, using commonly recognized billing 
                code sets, including the Current Procedural Terminology 
                code, the Healthcare Common Procedure Coding System 
                code, the diagnosis-related group, the National Drug 
                Code, and other nationally recognized identifier.
                    ``(B) The gross charge, as applicable, expressed as 
                a dollar amount, for each such item or service.
                    ``(C) The discounted cash price, as applicable, 
                expressed as a dollar amount, for each such item or 
                service (or, in the case no discounted cash price is 
                available for an item or service, the minimum cash 
                price accepted by the laboratory from self-pay 
                individuals for such item or service when provided in 
                such settings for the previous three years, expressed 
                as a dollar amount, as well as, with respect to prices 
                made public pursuant to subparagraph (A)(ii), a link to 
                a consumer-friendly document that clearly explains the 
                laboratory's charity care policy). The laboratory shall 
                accept the discounted cash price as payment in full 
                from any patient that chooses to pay in cash without 
                regard to the patient's coverage.
                    ``(D) The payer-specific negotiated charges, 
                expressed as a dollar amount and clearly associated 
                with the name of the applicable third party payer and 
                name of each plan, that apply to each such item or 
                service when provided in, as applicable, the inpatient 
                setting and outpatient department setting. If the 
                charges are based on an algorithm, percentage of 
                another amount, or other formula or criteria, the 
                clinical diagnostic laboratory also shall disclose such 
                algorithm, percentage, formula, or criteria as set 
                forth in its contract and any other terms, schedules, 
                exhibits, data, or other information referenced in any 
                such contract as shall be required to determine and 
                disclose the negotiated charge.
                    ``(E) The de-identified maximum and minimum 
                negotiated charges, as applicable, for each such item 
                or service, expressed as a non-zero dollar amount.
                    ``(F) Any other additional information the 
                Secretary may require for the purpose of improving the 
                accuracy of, or enabling consumers to easily understand 
                and compare, standard charges and prices for an item or 
                service, except information that is duplicative of any 
                other reporting requirement under this subsection. In 
                the case of standard charges and prices for an item or 
                service included as part of a bundled, per diem, 
                episodic, or other similar arrangement, the information 
                described in this subparagraph shall be made available 
                as determined appropriate by the Secretary.
            ``(3) Uniform method and format.--Not later than January 1, 
        2025, the Secretary shall establish a standard, uniform method 
        and format for applicable laboratories to use in compiling and 
        making public information pursuant to paragraph (1). Such 
        method and format--
                    ``(A) shall include a machine-readable spreadsheet 
                format containing the information described in 
                paragraph (2) for all items and services furnished by 
                each laboratory;
                    ``(B) may be similar to any template made available 
                by the Centers for Medicare & Medicaid Services (as 
                described in subsection (e));
                    ``(C) shall meet such standards as determined 
                appropriate by the Secretary in order to ensure the 
                accessibility and usability of such information; and
                    ``(D) shall be updated as determined appropriate by 
                the Secretary, in consultation with stakeholders.
            ``(4) Inclusion of ancillary services.--Any price or rate 
        for a specified clinical diagnostic laboratory test available 
        to be furnished by an applicable laboratory made publicly 
        available in accordance with paragraph (1) shall include the 
        price or rate (as applicable) for any ancillary item or service 
        (such as specimen collection services) that would normally be 
        furnished by such laboratory as part of such test, as specified 
        by the Secretary.
            ``(5) Enforcement.--
                    ``(A) In general.--In the case that the Secretary 
                determines that an applicable laboratory is not in 
                compliance with paragraph (1)--
                            ``(i) not later than 30 days after such 
                        determination, the Secretary shall notify such 
                        laboratory of such determination; and
                            ``(ii) if such laboratory continues to fail 
                        to comply with such paragraph after the date 
                        that is 90 days after such notification is 
                        sent, the Secretary may impose a civil monetary 
                        penalty in an amount not to exceed $300 for 
                        each (beginning with the day on which the 
                        Secretary first determined that such laboratory 
                        was failing to comply with such paragraph) 
                        during which such failure is ongoing.
                    ``(B) Increase authority.--In applying this 
                paragraph with respect to violations occurring in 2025 
                or a subsequent year, the Secretary may through notice 
                and comment rulemaking increase the per day limitation 
                on civil monetary penalties under subparagraph (A)(ii).
                    ``(C) Application of certain provisions.--The 
                provisions of section 1128A of the Social Security Act 
                (other than subsections (a) and (b) of such section) 
                shall apply to a civil monetary penalty imposed under 
                this paragraph in the same manner as such provisions 
                apply to a civil monetary penalty imposed under 
                subsection (a) of such section.
            ``(6) Provision of technical assistance.--The Secretary 
        shall, to the extent practicable, provide technical assistance 
        relating to compliance with the provisions of this subsection 
        to applicable laboratories requesting such assistance.
            ``(7) Definitions.--In this subsection:
                    ``(A) Applicable laboratory.--The term `applicable 
                laboratory' has the meaning given such term in section 
                414.502, of title 42, Code of Federal Regulations (or a 
                successor regulation), except that such term does not 
                include a laboratory with respect to which standard 
                charges and prices for specified clinical diagnostic 
                laboratory tests furnished by such laboratory are made 
                available by a hospital pursuant to subsection (e).
                    ``(B) Discounted cash price.--The term `discounted 
                cash price' means the charge that applies to an 
                individual who pays cash, or cash equivalent, for an 
                item or service.
                    ``(C) Gross charge.--The term `gross charge' means 
                the charge for an individual item or service that is 
                reflected on an applicable laboratory's chargemaster, 
                absent any discounts.
                    ``(D) Payer-specific negotiated charge.--The term 
                `payer-specific negotiated charge' means the charge 
                that an applicable laboratory has negotiated with a 
                third party payer for an item or service.
                    ``(E) Specified clinical diagnostic laboratory 
                test.--The term `specified clinical diagnostic 
                laboratory test' means a clinical diagnostic laboratory 
                test that is included on the list of shoppable services 
                specified by the Centers for Medicare & Medicaid 
                Services (as described in subsection (e)), other than 
                such a test that is only available to be furnished by a 
                single provider of services or supplier.
                    ``(F) Third party payer.--The term `third party 
                payer' means an entity that is, by statute, contract, 
                or agreement, legally responsible for payment of a 
                claim for a health care item or service.''.

SEC. 4. IMAGING TRANSPARENCY.

    Section 2718 of the Public Health Service Act (42 U.S.C. 300gg-18), 
as amended by section 3, is further amended by adding at the end the 
following:
    ``(g) Imaging Services Price Transparency.--
            ``(1) In general.--Beginning January 1, 2025, each provider 
        of services and supplier that receives payment from a group 
        health plan or health insurance issuer for furnishing a 
        specified imaging service, other than such a provider or 
        supplier with respect to which standard charges and prices for 
        such services furnished by such provider or supplier are made 
        available by a hospital pursuant to subsection (e), shall--
                    ``(A) make publicly available (in accordance with 
                paragraph (3)) on an internet website the information 
                described in paragraph (2) with respect to each such 
                service that such provider of services or supplier 
                furnishes; and
                    ``(B) ensure that such information is updated not 
                less frequently than annually.
            ``(2) Information described.--For purposes of paragraph 
        (1), the information described in this paragraph is, with 
        respect to a provider of services or supplier and a specified 
        imaging service, the following:
                    ``(A) A plain language description of each item or 
                service, accompanied by any applicable billing codes, 
                including modifiers, using commonly recognized billing 
                code sets, including the Current Procedural Terminology 
                code, the Healthcare Common Procedure Coding System 
                code, the diagnosis-related group, the National Drug 
                Code, and other nationally recognized identifier.
                    ``(B) The gross charge, as applicable, expressed as 
                a dollar amount, for each such item or service.
                    ``(C) The discounted cash price, as applicable, 
                expressed as a dollar amount, for each such item or 
                service (or, in the case no discounted cash price is 
                available for an item or service, the minimum cash 
                price accepted by the provider of services or supplier 
                from self-pay individuals for such item or service when 
                provided in such settings for the previous three years, 
                expressed as a dollar amount, as well as, with respect 
                to prices made public pursuant to subparagraph (A)(ii), 
                a link to a consumer-friendly document that clearly 
                explains the provider of services or supplier's charity 
                care policy). The provider of services or supplier 
                shall accept the discounted cash price as payment in 
                full from any patient that chooses to pay in cash 
                without regard to the patient's coverage.
                    ``(D) The payer-specific negotiated charges, 
                expressed as a dollar amount and clearly associated 
                with the name of the applicable third party payer and 
                name of each plan, that apply to each such item or 
                service when provided in, as applicable, the inpatient 
                setting and outpatient department setting. If the 
                charges are based on an algorithm, percentage of 
                another amount, or other formula or criteria, the 
                provider or supplier also shall disclose such 
                algorithm, percentage, formula, or criteria as set 
                forth in its contract and any other terms, schedules, 
                exhibits, data, or other information referenced in any 
                such contract as shall be required to determine and 
                disclose the negotiated charge.
                    ``(E) The de-identified maximum and minimum 
                negotiated charges, as applicable, for each such item 
                or service, expressed as a non-zero dollar amount.
                    ``(F) Any other additional information the 
                Secretary may require for the purpose of improving the 
                accuracy of, or enabling consumers to easily understand 
                and compare, standard charges and prices for an item or 
                service, except information that is duplicative of any 
                other reporting requirement under this subsection. In 
                the case of standard charges and prices for an item or 
                service included as part of a bundled, per diem, 
                episodic, or other similar arrangement, the information 
                described in this subparagraph shall be made available 
                as determined appropriate by the Secretary.
            ``(3) Uniform method and format.--Not later than January 1, 
        2025, the Secretary shall establish a standard, uniform method 
        and format for providers of services and suppliers to use in 
        making public information described in paragraph (2). Any such 
        method and format--
                    ``(A) shall include a machine-readable spreadsheet 
                format containing the information described in 
                paragraph (2) for all items and services furnished by 
                each provider of services and supplier described in 
                paragraph (1);
                    ``(B) may be similar to any template made available 
                by the Centers for Medicare & Medicaid Services (as 
                described in subsection (e));
                    ``(C) shall meet such standards as determined 
                appropriate by the Secretary in order to ensure the 
                accessibility and usability of such information; and
                    ``(D) shall be updated as determined appropriate by 
                the Secretary, in consultation with stakeholders.
            ``(4) Monitoring compliance.--The Secretary shall, through 
        notice and comment rulemaking and in consultation with the 
        Inspector General of the Department of Health and Human 
        Services, establish a process to monitor compliance with this 
        subsection.
            ``(5) Enforcement.--
                    ``(A) In general.--In the case that the Secretary 
                determines that a provider of services or supplier is 
                not in compliance with paragraph (1)--
                            ``(i) not later than 30 days after such 
                        determination, the Secretary shall notify such 
                        provider or supplier of such determination;
                            ``(ii) upon request of the Secretary, such 
                        provider or supplier shall submit to the 
                        Secretary, not later than 45 days after the 
                        date of such request, a corrective action plan 
                        to comply with such paragraph; and
                            ``(iii) if such provider or supplier 
                        continues to fail to comply with such paragraph 
                        after the date that is 90 days after such 
                        notification is sent (or, in the case of such a 
                        provider or supplier that has submitted a 
                        corrective action plan described in clause (ii) 
                        in response to a request so described, after 
                        the date that is 90 days after such 
                        submission), the Secretary may impose a civil 
                        monetary penalty in an amount not to exceed 
                        $300 for each day (beginning with the day on 
                        which the Secretary first determined that such 
                        provider or supplier was failing to comply with 
                        such paragraph) during which such failure to 
                        comply or failure to submit is ongoing.
                    ``(B) Increase authority.--In applying this 
                paragraph with respect to violations occurring in 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 of the Social Security Act 
                (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) No authority to waive or reduce penalty.--The 
                Secretary shall not grant or extend any waiver, delay, 
                tolling, or other mitigation of a civil monetary 
                penalty for violation of this subsection.
                    ``(E) Provision of technical assistance.--The 
                Secretary shall, to the extent practicable, provide 
                technical assistance relating to compliance with the 
                provisions of this subsection to providers of services 
                and suppliers requesting such assistance.
                    ``(F) Clarification of nonapplicability of other 
                enforcement provisions.--Notwithstanding any other 
                provision of this title, this paragraph shall be the 
                sole means of enforcing the provisions of this 
                subsection.
            ``(6) Specified imaging service defined.--the term 
        `specified imaging service' means an imaging service that is a 
        Centers for Medicare & Medicaid Services-specified shoppable 
        service (as described in subsection (e)).''.

SEC. 5. AMBULATORY SURGICAL CENTER PRICE TRANSPARENCY REQUIREMENTS.

    Section 2718 of the Public Health Service Act (42 U.S.C. 300gg-18), 
as amended by section 4, is further amended by adding at the end the 
following:
    ``(h) Ambulatory Surgery Center Transparency.--
            ``(1) In general.--Beginning January 1, 2025, each 
        specified ambulatory surgical center that receives payment from 
        a group health plan or health insurance issuer 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 a specified 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 machine-
                        readable 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 in a consumer-friendly 
                        format (as specified by the Secretary) 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 
                        included on the list described in subsection 
                        (e) that are furnished by such surgical center, 
                        and as many additional ambulatory surgical 
                        center-selected shoppable services (or all such 
                        additional services, if such surgical center 
                        furnishes fewer than 300 shoppable services) as 
                        may be necessary for a combined total of at 
                        least 300 shoppable services; and
                            ``(iii) with respect to each Centers for 
                        Medicare & Medicaid Services-specified 
                        shoppable service (as described in clause (ii)) 
                        that is not furnished by the ambulatory 
                        surgical center, an indication that such 
                        service is not so furnished.
                    ``(B) Information described.--For purposes of 
                subparagraph (A), the information described in this 
                subparagraph is, with respect to standard charges and 
                prices, as applicable, made public by a specified 
                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 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 minimum cash price accepted by the 
                        specified ambulatory surgical center from self-
                        pay individuals for such item or service when 
                        provided in such settings for the previous 
                        three years, expressed as a dollar amount, as 
                        well as, with respect to prices made public 
                        pursuant to subparagraph (A)(ii), a link to a 
                        consumer-friendly document that clearly 
                        explains the provider of services or supplier's 
                        charity care policy). The specified ambulatory 
                        surgical center shall accept the discounted 
                        cash price as payment in full from any patient 
                        that chooses to pay in cash without regard to 
                        the patient's coverage.
                            ``(iv) The payer-specific negotiated 
                        charges, expressed as a dollar amount and 
                        clearly associated with the name of the 
                        applicable third party payer and name of each 
                        plan, that apply to each such item or service 
                        when provided in, as applicable, the inpatient 
                        setting and outpatient department setting. If 
                        the charges are based on an algorithm, 
                        percentage of another amount, or other formula 
                        or criteria, the ambulatory surgical center 
                        also shall disclose such algorithm, percentage, 
                        formula, or criteria as set forth in its 
                        contract and any other terms, schedules, 
                        exhibits, data, or other information referenced 
                        in any such contract as shall be required to 
                        determine and disclose the negotiated charge.
                            ``(v) The de-identified maximum and minimum 
                        negotiated charges, as applicable, for each 
                        such item or service, expressed as a non-zero 
                        dollar amount.
                            ``(vi) Any other additional information the 
                        Secretary may require for the purpose of 
                        improving the accuracy of, or enabling 
                        consumers to easily understand and compare, 
                        standard charges and prices for an item or 
                        service, except information that is duplicative 
                        of any other reporting requirement under this 
                        subsection.
                    ``(C) Uniform method and format.--Not later than 
                January 1, 2025, the Secretary shall establish a 
                standard, uniform method and format for specified 
                ambulatory surgical centers to use in making public 
                standard charges pursuant to subparagraph (A)(i) and a 
                standard, uniform method and format for such centers to 
                use in making public prices pursuant to subparagraph 
                (A)(ii). Any such method and format--
                            ``(i) shall, in the case of such charges 
                        made public by an ambulatory surgical center, 
                        ensure that such charges are made available in 
                        a machine-readable format;
                            ``(ii) may be similar to any template made 
                        available by the Centers for Medicare & 
                        Medicaid Services (as described in subsection 
                        (e));
                            ``(iii) shall meet such standards as 
                        determined appropriate by the Secretary in 
                        order to ensure the accessibility and usability 
                        of such charges and prices; and
                            ``(iv) shall be updated as determined 
                        appropriate by the Secretary, in consultation 
                        with stakeholders.
            ``(3) No deemed compliance.--The availability of a price 
        estimator tool shall not be considered to deem compliance with 
        or otherwise vitiate the requirements of this subsection (aa). 
        Furthermore, the use of an estimator tool shall not be used for 
        purposes of compliance with any provisions in this subsection.
            ``(4) Monitoring compliance.--The Secretary shall, 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 ambulatory surgical center's compliance with 
        this subsection is reviewed not less frequently than once every 
        year.
            ``(5) Enforcement.--
                    ``(A) In general.--In the case of a specified 
                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.--A specified 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 day (beginning with the day 
                        on which the Secretary first determined that 
                        such hospital was not complying with such 
                        requirements) 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 a 
                        specified ambulatory surgical center under 
                        clause (i).
                            ``(iii) Application of certain 
                        provisions.--The provisions of section 1128A of 
                        the Social Security Act (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) No authority to waive or reduce 
                        penalty.--The Secretary shall not grant or 
                        extend any waiver, delay, tolling, or other 
                        mitigation of a civil monetary penalty for 
                        violation of this subsection.
            ``(6) Provision of technical assistance.--The Secretary 
        shall, to the extent practicable, provide technical assistance 
        relating to compliance with the provisions of this subsection 
        to specified ambulatory surgical centers requesting such 
        assistance.
            ``(7) 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) 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.
                    ``(C) 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.
                    ``(D) 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.
                    ``(E) Shoppable service.--The term `shoppable 
                service' means a service that can be scheduled by a 
                health care consumer in advance and includes all 
                ancillary items and services customarily furnished as 
                part of such service.
                    ``(F) Specified ambulatory surgical center.--The 
                term `specified ambulatory surgical center' means an 
                ambulatory surgical center with respect to which a 
                hospital (or any person with an ownership or control 
                interest (as defined in section 1124(a)(3) of the 
                Social Security Act) in a hospital) is a person with an 
                ownership or control interest (as so defined).
                    ``(G) Third party payer.--The term `third party 
                payer' means an entity that is, by statute, contract, 
                or agreement, legally responsible for payment of a 
                claim for a health care item or service.''.

SEC. 6. STRENGTHENING HEALTH COVERAGE TRANSPARENCY REQUIREMENTS.

    (a) Transparency in Coverage.--Section 1311(e)(3)(C) of the Patient 
Protection and Affordable Care Act (42 U.S.C. 18031(e)(3)(C)) is 
amended--
            (1) by striking ``The Exchange'' and inserting the 
        following:
                            ``(i) In general.--The Exchange'';
            (2) in clause (i), as inserted by paragraph (1)--
                    (A) by striking ``participating provider'' and 
                inserting ``provider'';
                    (B) by inserting ``shall include the information 
                specified in clause (ii) and'' after ``such 
                information'';
                    (C) by striking ``an Internet website'' and 
                inserting ``a self-service tool that meets the 
                requirements of clause (iii)''; and
                    (D) by striking ``and such other'' and all that 
                follows through the period and inserting ``or, at the 
                option such individual, through a paper or phone 
                disclosure (as selected by such individual and provided 
                at no cost to such individual) that meets such 
                requirements as the Secretary may specify.''; and
            (3) by adding at the end the following new clauses:
                            ``(ii) Specified information.--For purposes 
                        of clause (i), the information specified in 
                        this clause is, with respect to benefits 
                        available under a health plan for an item or 
                        service furnished by a health care provider, 
                        the following:
                                    ``(I) If such provider is a 
                                participating provider with respect to 
                                such item or service, the in-network 
                                rate (as defined in subparagraph (F)) 
                                for such item or service.
                                    ``(II) If such provider is not 
                                described in subclause (I), the maximum 
                                allowed amount for such item or 
                                service.
                                    ``(III) The amount of cost sharing 
                                (including deductibles, copayments, and 
                                coinsurance) that the individual will 
                                incur for such item or service (which, 
                                in the case such item or service is to 
                                be furnished by a provider described in 
                                subclause (II), shall be calculated 
                                using the maximum amount described in 
                                such subclause).
                                    ``(IV) The amount the individual 
                                has already accumulated with respect to 
                                any deductible or out of pocket maximum 
                                under the plan (broken down, in the 
                                case separate deductibles or maximums 
                                apply to separate individuals enrolled 
                                in the plan, by such separate 
                                deductibles or maximums, in addition to 
                                any cumulative deductible or maximum).
                                    ``(V) In the case such plan imposes 
                                any frequency or volume limitations 
                                with respect to such item or service 
                                (excluding medical necessity 
                                determinations), the amount that such 
                                individual has accrued towards such 
                                limitation with respect to such item or 
                                service.
                                    ``(VI) Any prior authorization, 
                                concurrent review, step therapy, fail 
                                first, or similar requirements 
                                applicable to coverage of such item or 
                                service under such plan.
                            ``(iii) Self-service tool.--For purposes of 
                        clause (i), a self-service tool established by 
                        a health plan meets the requirements of this 
                        clause if such tool--
                                    ``(I) is based on an internet 
                                website;
                                    ``(II) provides for real-time 
                                responses to requests described in such 
                                clause;
                                    ``(III) is updated in a manner such 
                                that information provided through such 
                                tool is timely and accurate;
                                    ``(IV) allows such a request to be 
                                made with respect to an item or service 
                                furnished by--
                                            ``(aa) a specific provider 
                                        that is a participating 
                                        provider with respect to such 
                                        item or service;
                                            ``(bb) all providers that 
                                        are participating providers 
                                        with respect to such plan and 
                                        such item or service; or
                                            ``(cc) a provider that is 
                                        not described in item (bb);
                                    ``(V) 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
                                    ``(VI) holds a member harmless for 
                                the amount of any difference in excess 
                                of the amount of the individual's 
                                responsibility generated by the self-
                                service tool and the amount ultimately 
                                billed or charged to the individual.''.
    (b) Disclosure of Additional Information.--Section 1311(e)(3) of 
the Patient Protection and Affordable Care Act (42 U.S.C. 18031(e)(3)) 
is amended by adding at the end the following new subparagraphs:
                    ``(E) Rate and payment information.--
                            ``(i) In general.--Not later than January 
                        1, 2025, and every month thereafter, each 
                        health plan shall submit to the Exchange, the 
                        Secretary, the State insurance commissioner, 
                        and make available to the public, the rate and 
                        payment information described in clause (ii) in 
                        accordance with clause (iii).
                            ``(ii) Rate and payment information 
                        described.--For purposes of clause (i), the 
                        rate and payment information described in this 
                        clause is, with respect to a health plan, the 
                        following:
                                    ``(I) With respect to each item or 
                                service for which benefits are 
                                available under such plan (expressed as 
                                a dollar amount), including 
                                prescription drugs, identified by CPT, 
                                HCPCS, DRG, NDC, or other applicable 
                                nationally recognized identifier, 
                                including any applicable code 
                                modifiers, and accompanied by a brief 
                                description of the item or service, the 
                                in-network rate in effect as of the 
                                date of the submission of such 
                                information with each provider 
                                (identified by national provider 
                                identifier) that is a participating 
                                provider with respect to such item or 
                                service, other than such a rate in 
                                effect with a provider that has 
                                submitted no claims for such item or 
                                service to such plan.
                                    ``(II) With respect to each drug 
                                (identified by National Drug Code, J-
                                code, or other commonly recognized 
                                billing code used for drugs) for which 
                                benefits are available under such plan:
                                            ``(aa) The in-network rate 
                                        (expressed as a dollar amount), 
                                        including the individual and 
                                        total amounts for any bundled 
                                        rates, in effect as of the 
                                        first day of the month in which 
                                        such information is made public 
                                        with each provider that is a 
                                        participating provider with 
                                        respect to such drug.
                                            ``(bb) The historical net 
                                        price paid by such plan (net of 
                                        rebates, discounts, and price 
                                        concessions) (expressed as a 
                                        dollar amount) for such drug 
                                        dispensed or administered 
                                        during the 90-day period 
                                        beginning 180 days before such 
                                        date of submission to each 
                                        provider that was a 
                                        participating provider with 
                                        respect to such drug, broken 
                                        down by each such provider 
                                        (identified by national 
                                        provider identifier), other 
                                        than such an amount paid to a 
                                        provider that has submitted no 
                                        claims for such drug to such 
                                        plan.
                                    ``(III) With respect to each item 
                                or service for which benefits are 
                                available under such plan (expressed as 
                                a dollar amount), identified by CPT, 
                                DRG, HCPCS, NDC, or other applicable 
                                nationally recognized identifier, 
                                including any applicable code 
                                modifiers, and accompanied by a brief 
                                description of the item or service, the 
                                amount billed or charged by the 
                                provider, and the amount allowed by the 
                                plan, for each such item or service 
                                furnished during the 90-day period 
                                beginning 180 days before such date of 
                                submission by each provider that was 
                                not a participating provider with 
                                respect to such item or service, broken 
                                down by each such provider (identified 
                                by national provider identifier), other 
                                than items and services with respect to 
                                which no claims for such item or 
                                service were submitted to such plan 
                                during such period.
                            ``(iii) Manner of submission.--Rate and 
                        payment information required to be submitted 
                        and made available under this subparagraph 
                        shall be so submitted and so made available as 
                        follows:
                                    ``(I) Information shall be 
                                contained in 3 separate machine-
                                readable files corresponding to the 
                                information described in each of 
                                subclauses (I) through (III) of clause 
                                (ii) that meet such requirements as 
                                specified by the Secretary through 
                                rulemaking, in consultation with the 
                                Secretaries of Labor and the Treasury 
                                to apply comparable requirements to 
                                group health plans and to entities 
                                providing benefit management or other 
                                third-party administration services on 
                                a contractual basis with a group health 
                                plan.
                                    ``(II) Requirements specified by 
                                the Secretary through rulemaking shall 
                                ensure that:
                                            ``(aa) Such files are 
                                        limited to an appropriate size, 
                                        are made available in a widely 
                                        available format that allows 
                                        for information contained in 
                                        such files to be compared 
                                        across health plans, and are 
                                        accessible to individuals at no 
                                        cost and without the need to 
                                        establish a user account or 
                                        provider other credentials.
                                            ``(bb) The rates, amounts, 
                                        and prices to be disclosed 
                                        include contractual terms 
                                        containing calculation 
                                        formulae, pricing 
                                        methodologies, and other 
                                        information necessary to 
                                        determine the dollar value of 
                                        reimbursement.
                                            ``(cc) Each such file 
                                        includes each of the following 
                                        data elements:

                                                    ``(AA) A numerical 
                                                identifier for the 
                                                group health plan and/
                                                or health insurance 
                                                issuer (such as a 
                                                Health Insurance 
                                                Oversight System 
                                                identifier).

                                                    ``(BB) A plain-
                                                language description of 
                                                the item or service 
                                                (including, for drugs, 
                                                the proprietary and 
                                                nonproprietary name 
                                                assigned).

                                                    ``(CC) The billing 
                                                code, including any 
                                                applicable modifiers, 
                                                associated with such 
                                                item or service, 
                                                including the 
                                                Healthcare Common 
                                                Procedure Coding System 
                                                code, diagnosis-related 
                                                group, national drug 
                                                code, or other commonly 
                                                recognized code set.

                                                    ``(DD) The place of 
                                                service code.

                                                    ``(EE) The National 
                                                Provider Identifier or 
                                                provider Tax 
                                                Identification Number.

                                    ``(III) The rate and payment 
                                information disclosed under subclauses 
                                (I) through (III) of clause (ii) shall 
                                be separately delineated for each item 
                                or service, regardless of whether such 
                                item or service is reimbursed as a part 
                                of a bundle, episode, or other grouping 
                                of items and services.
                                    ``(IV) An officer or executive of 
                                competent authority shall attest to the 
                                accuracy and completeness of 
                                information submitted and made 
                                available under this subparagraph. Such 
                                attestation shall be deemed material to 
                                payments from the Federal Government 
                                received by the group health plan or 
                                health insurance issuer.
                                    ``(V) Regulations promulgated 
                                pursuant to this section shall provide 
                                that:
                                            ``(aa) The Secretary shall 
                                        audit the three machine-
                                        readable files required by 
                                        subparagraph (E)(ii) posted by 
                                        no fewer than 20 group health 
                                        plans or health insurance 
                                        issuers.
                                            ``(bb) The Secretary of 
                                        Labor shall audit the three 
                                        machine-readable files required 
                                        by subparagraph (E)(ii) posted 
                                        by no fewer than 200 group 
                                        health plans or service 
                                        providers furnishing third-
                                        party administrator services to 
                                        a group health plan.
                                            ``(cc) Findings, 
                                        conclusions, and enforcement 
                                        actions taken based on audits 
                                        of the machine-readable files 
                                        shall be reported annually to 
                                        Congress no later than July 1 
                                        of the calendar year during 
                                        which the files were audited. 
                                        Such report to Congress shall 
                                        be accessible to the public.
                            ``(iv) User guide.--Each health plan shall 
                        make available to the public instructions 
                        written in plain language explaining how 
                        individuals may search for information 
                        described in clause (ii) in files submitted in 
                        accordance with clause (iii).
                    ``(F) Definitions.--In this paragraph:
                            ``(i) Participating provider.--The term 
                        `participating provider' has the meaning given 
                        such term in section 2799A-1 of the Public 
                        Health Service Act.
                            ``(ii) 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. If the 
                        rate is based on an algorithm, percentage of 
                        another amount, or other formula or criteria, 
                        the health plan also shall disclose such 
                        algorithm, percentage, formula, or criteria as 
                        set forth in its contract and any other terms, 
                        schedules, exhibits, data, or other information 
                        referenced in any such contract as shall be 
                        required to determine and disclose the 
                        negotiated rate.
                    ``(G) Applicability to accountable care 
                organizations.--An applicable ACO participating in the 
                Medicare Shared Savings Program, as defined in Section 
                1899 of the Social Security Act (42 U.S.C. Sec.  
                1395jjj), shall be subject to the requirements of this 
                paragraph as if such applicable ACO is a group health 
                plan or health insurance issuer.
                    ``(H) Enforcement.--Each year, the Secretary shall 
                audit the three machine-readable files required by 
                subparagraph (E)(ii) posted by no fewer than 20 group 
                health plans or health insurance issuers.''.
    (c) Effective Date.--
            (1) In general.--The amendments made by subsection (a) 
        shall apply beginning January 1, 2025.
            (2) Continued applicability of rules for previous years.--
        Nothing in the amendments made by this section 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) 
        before January 1, 2025.

SEC. 7. INCREASING GROUP HEALTH PLAN ACCESS TO HEALTH DATA.

    (a) Group Health Plan Access to Information.--
            (1) In general.--Paragraph (2) of section 408(b) of the 
        Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 
        1108(b)) is amended by adding at the end the following new 
        subparagraphs:
                    ``(C) No contract or arrangement for services 
                between a group health plan and any other entity, 
                including a health care provider (including a health 
                care facility), network or association of providers, 
                service provider offering access to a network of 
                providers, third-party administrator, or pharmacy 
                benefit manager (collectively, `Covered Service 
                Providers'), is reasonable within the meaning of this 
                paragraph unless such contract or arrangement--
                            ``(i) allows the responsible group health 
                        plan access to all claims and encounter 
                        information, and any documentation supporting 
                        claim payments, including, but not limited to, 
                        medical records and policy documents, or data 
                        described in section 724(a)(1)(B) to--
                                    ``(I) enable such entity to comply 
                                with the terms of the plan and any 
                                applicable law; and
                                    ``(II) determine the accuracy or 
                                reasonableness of payment; and
                            ``(ii) does not--
                                    ``(I) unreasonably limit or delay 
                                access to such information or data;
                                    ``(II) limit the volume of claims 
                                and encounter information or data that 
                                the group health plan may access during 
                                an audit;
                                    ``(III) limit the disclosure of 
                                pricing terms for value-based payment 
                                arrangements or capitated payment 
                                arrangements, including--
                                            ``(aa) payment calculations 
                                        and formulas;
                                            ``(bb) quality measures;
                                            ``(cc) contract terms;
                                            ``(dd) payment amounts;
                                            ``(ee) measurement periods 
                                        for all incentives; and
                                            ``(ff) other payment 
                                        methodologies used by an 
                                        entity, including a health care 
                                        provider (including a health 
                                        care facility), network or 
                                        association of providers, 
                                        service provider offering 
                                        access to a network of 
                                        providers, third-party 
                                        administrator, or pharmacy 
                                        benefit manager;
                                    ``(IV) limit the disclosure of 
                                overpayments and overpayment recovery 
                                terms;
                                    ``(V) limit the right of the group 
                                health plan to select an auditor or 
                                define audit scope or frequency;
                                    ``(VI) otherwise limit or unduly 
                                delay the group health plan from 
                                accessing claims and encounter 
                                information or data in a daily batch.
                                    ``(VII) limit the disclosure of 
                                fees charged to the group health plan 
                                related to plan administration and 
                                claims processing, including 
                                renegotiation fees, access fees, 
                                repricing fees, or enhanced review 
                                fees;
                                    ``(VIII) limit the right of the 
                                group health plan to request action on 
                                any suspect claim payments; or
                                    ``(IX) limit public disclosure of 
                                de-identified or aggregate information.
                    ``(D) Privacy requirements.--Covered Service 
                Providers shall provide information under this 
                paragraph in a manner consistent with the privacy and 
                security regulations promulgated under the Health 
                Insurance Portability and Accountability Act (HIPAA). 
                This subparagraph shall not be read to abridge or limit 
                the disclosure requirements under this paragraph or to 
                impose additional privacy or security requirements on 
                Covered Service Providers or plan sponsors.
                    ``(E) Disclosure and redisclosure; limitation to 
                business associates.--A group health plan receiving 
                information or data under this paragraph may disclose 
                such information only to the entity from which the 
                information or data was received, the group health plan 
                or plan sponsor to which the information or data 
                pertains, or to that entity's business associates as 
                defined in section 160.103 of title 45, Code of Federal 
                Regulations, or as otherwise permitted by the HIPAA 
                Privacy Rule (45 CFR parts 160 and 164, subparts A and 
                E).
                    ``(F) Data standards.--Information made available 
                under this section shall conform to the following 
                standards:
                            ``(i) Institutional, professional, and 
                        dental claims received from a healthcare 
                        provider shall be made available to the group 
                        health plan as ASC X12N 837 files. The files 
                        shall be unmodified copies of the files sent 
                        from the provider. In the event that paper 
                        claims are sent by the provider, they shall be 
                        converted to the ASC X12N 837 electronic 
                        format. Files shall be accessible to the plan 
                        at no cost to the group health plan.
                            ``(ii) All claim payment (or EFT, 
                        electronic funds transfer) and electronic 
                        remittance advice (ERA) notices sent by a 
                        Covered Service Provider shall be made 
                        available to the group health plan as ASC X12N 
                        835 files. The files shall be unmodified copies 
                        of the files sent by the Covered Service 
                        Provider to the healthcare provider. Files 
                        shall be accessible at no cost to the group 
                        health plan.
                            ``(iii) The contractual terms containing 
                        calculation formulae, pricing methodologies, 
                        and other information used to determine the 
                        dollar value of reimbursement.
                            ``(iv) All non-claim costs shall be 
                        itemized and made available to the group health 
                        plan in real time through a web-based portal, 
                        through an API, and through a downloadable CSV 
                        file.''.
            (2) Civil enforcement.--
                    (A) In general.--Subsection (c) of section 502 of 
                such Act (29 U.S.C. 1132) is amended by adding at the 
                end the following new paragraph: ``(13) In the case of 
                an agreement between a group health plan and a health 
                care provider (including a health care facility), 
                network or association of providers, service provider 
                offering access to a network of providers, third-party 
                administrator, or pharmacy benefit manager, that 
                violates the provisions of section 724, the Secretary 
                may assess a civil penalty against such provider, 
                network or association, service provider offering 
                access to a network of providers, third-party 
                administrator, pharmacy benefit manager, or other 
                service provider in the amount of $10,000 for each day 
                during which such violation continues. Such penalty 
                shall be in addition to other penalties as may be 
                prescribed by law.
                    (B) Conforming amendment.--Paragraph (6) of section 
                502(a) of such Act is amended by striking ``or (9)'' 
                and inserting ``(9), or (13)''.
            (3) Existing provisions void.--Section 410 of such Act is 
        amended by adding at the end the following:
    ``(c) Any provision in an agreement or instrument shall be void as 
against public policy if such provision--
            ``(1) unduly delays or limits a group health plan from 
        accessing the claims and encounter information or data 
        described in section 724(a)(1)(B); or
            ``(2) violates the requirements of section 408(b)(2)(C).''.
            (4) Technical amendment.--Clause (i) of section 
        408(b)(2)(B) of such Act is amended by striking ``this clause'' 
        and inserting ``this paragraph''.
    (b) Updated Attestation for Price and Quality Information.--Section 
724(a)(3) of the Employee Retirement Income Security Act of 1974 (29 
U.S.C. 1185m(a)(3)) is amended to read as follows:
            ``(3) Attestation.--
                    ``(A) In general.--Subject to subparagraph (C), the 
                group health plan or health insurance issuer offering 
                group health insurance coverage shall annually submit 
                to the Secretary an attestation that such plan or 
                issuer of such coverage is in compliance with the 
                requirements of this subsection. Such attestation shall 
                also include a statement verifying that--
                            ``(i) the information or data described 
                        under subparagraphs (A) and (B) of paragraph 
                        (1) is available upon request and provided to 
                        the group health plan, the plan administrator, 
                        or the issuer in a timely manner; and
                            ``(ii) there are no terms in the agreement 
                        under such paragraph (1) that directly or 
                        indirectly restrict or unduly delay a group 
                        health plan, the plan administrator, or the 
                        issuer from auditing, reviewing, or otherwise 
                        accessing such information, except as permitted 
                        under section 408(b)(2)(C).
                    ``(B) Limitation on submission.--Subject to clause 
                (ii), a group health plan or issuer offering group 
                health insurance coverage may not enter into an 
                agreement with a third-party administrator or other 
                service provider to submit the attestation required 
                under subparagraph (A).
                    ``(C) Exception.--In the case of a group health 
                plan or issuer offering group health insurance coverage 
                that is unable to obtain the information or data needed 
                to submit the attestation required under subparagraph 
                (A), such plan or issuer may submit a written statement 
                in lieu of such attestation that includes--
                            ``(i) an explanation of why such plan or 
                        issuer was unsuccessful in obtaining such 
                        information or data, including whether such 
                        plan or issuer was limited or prevented from 
                        auditing, reviewing, or otherwise accessing 
                        such information or data;
                            ``(ii) a description of the efforts made by 
                        the group health plan to remove any gag clause 
                        provisions from the agreement under paragraph 
                        (1); and
                            ``(iii) a description of any response by 
                        the third-party administrator or other service 
                        provider with respect to efforts to comply with 
                        the attestation requirement under subparagraph 
                        (A).''.
    (c) Effective Date.--The amendments made by subsections (a) and (b) 
shall apply with respect to a plan beginning with the first plan year 
that begins on or after the date that is 1 year after the date of 
enactment of this Act.

SEC. 8. PREEMPTION ONLY IN EVENT OF CONFLICT.

    The provisions of sections 2 through 5 of this Act (including the 
amendments made by such sections) shall not supersede any provision of 
State law which establishes, implements, or continues in effect any 
requirement or prohibition related to health care price transparency, 
except to the extent that such requirement or prohibition prevents the 
application of a requirement or prohibition of such sections (or 
amendment). Nothing in this section shall be construed to affect health 
plans established under the Employee Retirement Income Security Act of 
1974.
                                 <all>
```