II 

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. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Health Care Prices 

5 Revealed and Information to Consumers Explained Trans6 parency Act’’ or the ‘‘Health Care PRICE Transparency 

7 Act 2.0’’. 


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1 SEC. 2. STRENGTHENING HOSPITAL PRICE TRANSPARENCY 

2 REQUIREMENTS. 

3 (a) IN GENERAL.—Section 2718(e) of the Public 

4 Health Service Act (42 U.S.C. 300gg–18(e)) is amended 

5 to read as follows: 

6 ‘‘(e) STANDARD HOSPITAL CHARGES.— 

7 ‘‘(1) IN GENERAL.— 

8 ‘‘(A) DISCLOSURE OF STANDARD

9 CHARGES.—For purposes of paragraph (1), the 

10 price transparency requirement described in 

11 this paragraph is, with respect to a hospital, 

12 that such hospital, in accordance with a method 

13 and format established by the Secretary under 

14 subparagraph (C), compile and make public 

15 (without subscription and free of charge) for 

16 each month— 

17 ‘‘(i) all of the hospital’s standard 

18 charges (including the information de19 scribed in subparagraph (B)) for each item 

20 and service furnished by such hospital; and 

21 ‘‘(ii) information in a consumer22 friendly format (as specified by the Sec23 retary)— 

24 ‘‘(I) on the hospital’s prices (in25 cluding the information described in 

26 subparagraph (B)) for as many of the 


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1 Centers for Medicare & Medicaid 

2 Services-specified shoppable services 

3 that are furnished by the hospital, 

4 and as many additional hospital-se5 lected shoppable services (or all such 

6 additional services, if such hospital 

7 furnishes fewer than 300 shoppable 

8 services) as may be necessary for a 

9 combined total of at least 300 

10 shoppable services through December 

11 31, 2024, after which the hospital’s 

12 prices shall include all shoppable serv13 ices; and 

14 ‘‘(II) that includes, with respect 

15 to each Centers for Medicare & Med16 icaid Services-specified shoppable 

17 service that is not furnished by the 

18 hospital, an indication that such serv19 ice is not so furnished. 

20 ‘‘(B) STANDARD CHARGES DESCRIBED.— 

21 For purposes of subparagraph (A), the informa22 tion described in this subparagraph is, with re23 spect to standard charges and prices, as appli24 cable, made public by a hospital, the following: 


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1 ‘‘(i) A plain language description of 

2 each item or service, accompanied by any 

3 applicable billing codes, including modi4 fiers, using commonly recognized billing 

5 code sets, including the Current Proce6 dural Terminology code, the Healthcare 

7 Common Procedure Coding System code, 

8 the diagnosis-related group, the National 

9 Drug Code, and other nationally recog10 nized identifier. 

11 ‘‘(ii) The gross charge, as applicable, 

12 expressed as a dollar amount, for each 

13 such item or service, when provided in, as 

14 applicable, the inpatient setting and out15 patient department setting. 

16 ‘‘(iii) The discounted cash price, as 

17 applicable, expressed as a dollar amount, 

18 for each such item or service when pro19 vided in, as applicable, the inpatient set20 ting and outpatient department setting (or, 

21 in the case no discounted cash price is 

22 available for an item or service, the min23 imum cash price accepted by the hospital 

24 from self-pay individuals for such item or 

25 service, expressed as a dollar amount, as 


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1 well as, with respect to prices made public 

2 pursuant to subparagraph (A)(ii), a link to 

3 a consumer-friendly document that clearly 

4 explains the hospital’s charity care policy). 

5 The hospital shall accept the discounted 

6 cash price as payment in full from any pa7 tient that chooses to pay in cash without 

8 regard to the patient’s coverage. 

9 ‘‘(iv) The payer-specific negotiated 

10 charges, expressed as a dollar amount and 

11 clearly associated with the name of the ap12 plicable third party payer and name of 

13 each plan, that apply to each such item or 

14 service when provided in, as applicable, the 

15 inpatient setting and outpatient depart16 ment setting. If the charges are based on 

17 an algorithm, percentage of another 

18 amount, or other formula or criteria, the 

19 hospital also shall disclose such algorithm, 

20 percentage, formula, or criteria as set forth 

21 in its contract and any other terms, sched22 ules, exhibits, data, or other information 

23 referenced in any such contract as shall be 

24 required to determine and disclose the ne25 gotiated charge. 


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1 ‘‘(v) The de-identified maximum and 

2 minimum negotiated charges, as applica3 ble, for each such item or service, ex4 pressed as a non-zero dollar amount. 

5 ‘‘(vi) Any other additional information 

6 the Secretary may require for the purpose 

7 of improving the accuracy of, or enabling 

8 consumers to easily understand and com9 pare, standard charges and prices for an 

10 item or service, except information that is 

11 duplicative of any other reporting require12 ment under this subsection. In the case of 

13 standard charges and prices for an item or 

14 service included as part of a bundled, per 

15 diem, episodic, or other similar arrange16 ment, the information described in this 

17 subparagraph shall be made available as 

18 determined appropriate by the Secretary. 

19 ‘‘(C) UNIFORM METHOD AND FORMAT.— 

20 Not later than January 1, 2025, the Secretary 

21 shall establish a standard, uniform method and 

22 format for hospitals to use in compiling and 

23 making public standard charges pursuant to 

24 subparagraph (A)(i) and a standard, uniform 

25 method and format for such hospitals to use in 


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1 compiling and making public prices pursuant to 

2 subparagraph (A)(ii). Such methods and for3 mats— 

4 ‘‘(i) shall, in the case of such method 

5 and format for making public standard 

6 charges pursuant to subparagraph (A)(i), 

7 ensure that such charges are made avail8 able in a machine-readable spreadsheet for9 mat; 

10 ‘‘(ii) may be similar to any template 

11 made available by the Centers for Medicare 

12 & Medicaid Services as of the date of the 

13 enactment of this subparagraph; 

14 ‘‘(iii) shall meet such standards as de15 termined appropriate by the Secretary in 

16 order to ensure the accessibility and 

17 usability of such charges and prices; and 

18 ‘‘(iv) shall be updated as determined 

19 appropriate by the Secretary, in consulta20 tion with stakeholders. 

21 ‘‘(2) NO DEEMED COMPLIANCE.—The avail22 ability of a price estimator tool shall not be consid23 ered to deem compliance with or otherwise vitiate 

24 the requirements of paragraph (2)(A)(ii) or any 

25 other requirements of this section. Furthermore, the 


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1 use of an estimator tool shall not be used for pur2 poses of compliance with any provisions in this Sec3 tion. 

4 ‘‘(3) MONITORING COMPLIANCE.—The Sec5 retary shall, in consultation with the Inspector Gen6 eral of the Department of Health and Human Serv7 ices, establish a process to monitor compliance with 

8 this subsection. Such process shall ensure that each 

9 hospital’s compliance with this subsection is re10 viewed not less frequently than once every year. 

11 ‘‘(4) ATTESTATION.—A senior official from 

12 each hospital (the Chief Executive Officer, Chief Fi13 nancial Officer, or an official of equivalent seniority) 

14 shall attest to the accuracy and completeness of the 

15 disclosures made in accordance with the hospital 

16 price transparency requirements set forth in this 

17 regulation. Such attestation shall be deemed to be 

18 material to payment from the Federal Government 

19 to the hospital. 

20 ‘‘(5) ENFORCEMENT.— 

21 ‘‘(A) IN GENERAL.—In the case of a hos22 pital that fails to comply with the requirements 

23 of this subsection, not later than 30 days after 

24 the date on which the Secretary determines 

25 such failure exists, the Secretary shall submit 


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1 to such hospital a notification of such deter2 mination, which shall include a request for a 

3 corrective action plan to comply with such re4 quirements. 

5 ‘‘(B) CIVIL MONETARY PENALTY.— 

6 ‘‘(i) IN GENERAL.—In addition to any 

7 other enforcement actions or penalties that 

8 may apply under another provision of law, 

9 a hospital that has received a request for 

10 a corrective action plan under subpara11 graph (A) and fails to comply with the re12 quirements of this subsection by the date 

13 that is 45 days after such request is made 

14 shall be subject to a civil monetary penalty 

15 of an amount specified by the Secretary for 

16 each day (beginning with the day on which 

17 the Secretary first determined that such 

18 hospital was not complying with such re19 quirements) during which such failure was 

20 ongoing. Such amount shall not exceed— 

21 ‘‘(I) in the case of a hospital with 

22 30 or fewer beds, $300 per day; 

23 ‘‘(II) in the case of a hospital 

24 with more than 30 beds but fewer 

25 than 101 beds, $10 per bed per day 


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1 (or, in the case of such a hospital that 

2 has been noncompliant with such re3 quirements for a 1-year period or 

4 longer, beginning with the first day 

5 following such 1-year period, $12.50 

6 per bed per day); 

7 ‘‘(III) in the case of a hospital 

8 with more than 100 beds but fewer 

9 than 301 beds, $15 per bed per day 

10 (or, in the case of such a hospital that 

11 has been noncompliant with such re12 quirements for a 1-year period or 

13 longer, beginning with the first day 

14 following such 1-year period, $17.50 

15 per bed per day); 

16 ‘‘(IV) in the case of a hospital 

17 with more than 300 beds but fewer 

18 than 501 beds, $20 per bed per day 

19 (or, in the case of such a hospital that 

20 has been noncompliant with such re21 quirements for a 1-year period or 

22 longer, beginning with the first day 

23 following such 1-year period, $25 per 

24 bed per day); and 


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1 ‘‘(V) in the case of a hospital 

2 with more than 500 beds, $25 per bed 

3 per day (or, in the case of such a hos4 pital that has been noncompliant with 

5 such requirements for a 1-year period 

6 or longer, beginning with the first day 

7 following such 1-year period, $35 per 

8 bed per day). 

9 ‘‘(ii) INCREASE AUTHORITY.—In ap10 plying this subparagraph with respect to 

11 violations occurring in 2027 or a subse12 quent year, the Secretary may through no13 tice and comment rulemaking increase— 

14 ‘‘(I) the limitation on the per day 

15 amount of any penalty applicable to a 

16 hospital under clause (i)(I); 

17 ‘‘(II) the limitations on the per 

18 bed per day amount of any penalty 

19 applicable under any of subclauses 

20 (II) through (V) of clause (i); and 

21 ‘‘(III) the limitation on the in22 crease of any penalty applied under 

23 clause (iii) pursuant to the amounts 

24 specified in subclause (II) of such 

25 clause. 


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1 ‘‘(iii) PERSISTENT NONCOMPLI2 ANCE.— 

3 ‘‘(I) IN GENERAL.—In the case 

4 of a hospital that the Secretary has 

5 determined to be knowingly and will6 fully noncompliant with the provisions 

7 of this subsection two or more times 

8 during a 1-year period, the Secretary 

9 may increase any penalty otherwise 

10 applicable under this subparagraph by 

11 the amount specified in subclause (II) 

12 with respect to such hospital and may 

13 require such hospital to complete such 

14 additional corrective actions plans as 

15 the Secretary may specify. 

16 ‘‘(II) SPECIFIED AMOUNT.—For 

17 purposes of subclause (I), the amount 

18 specified in this subclause is, with re19 spect to a hospital— 

20 ‘‘(aa) with more than 30 

21 beds but fewer than 101 beds, an 

22 amount that is not less than 

23 $500,000 and not more than 

24 $1,000,000; 


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1 ‘‘(bb) with more than 100 

2 beds but fewer than 301 beds, an 

3 amount that is greater than 

4 $1,000,000 and not more than 

5 $2,000,000; 

6 ‘‘(cc) with more than 300 

7 beds but fewer than 501 beds, an 

8 amount that is greater than 

9 $2,000,000 and not more than 

10 $4,000,000; and 

11 ‘‘(dd) with more than 500 

12 beds, and amount that is not less 

13 than $5,000,000 and not more 

14 than $10,000,000. 

15 ‘‘(iv) PROVISION OF TECHNICAL AS16 SISTANCE.—The Secretary may, to the ex17 tent practicable, provide technical assist18 ance relating to compliance with the provi19 sions of this section to hospitals requesting 

20 such assistance. 

21 ‘‘(v) APPLICATION OF CERTAIN PROVI22 SIONS.—The provisions of section 1128A 

23 (other than subsections (a) and (b) of such 

24 section) shall apply to a civil monetary 

25 penalty imposed under this subparagraph 


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1 in the same manner as such provisions 

2 apply to a civil monetary penalty imposed 

3 under subsection (a) of such section. 

4 ‘‘(C) NO WAIVER.—The Secretary shall not 

5 grant or extend any waiver, delay, tolling, or 

6 other mitigation of a civil monetary penalty for 

7 violation of this subsection. 

8 ‘‘(6) DEFINITIONS.—For purposes of this sub9 section: 

10 ‘‘(A) DISCOUNTED CASH PRICE.—The 

11 term ‘discounted cash price’ means the min12 imum charge that the hospital accepts from an 

13 individual who pays cash, or cash equivalent, 

14 for a hospital-furnished item or service. 

15 ‘‘(B) GROSS CHARGE.—The term ‘gross 

16 charge’ means the charge for an individual item 

17 or service that is reflected on a hospital’s 

18 chargemaster, absent any discounts. 

19 ‘‘(C) HOSPITAL.—The term ‘hospital’ 

20 means a hospital (as defined in section 1861(e) 

21 of the Social Security Act), a critical access 

22 hospital (as defined in section 1861(mmm)(1) 

23 of the Social Security Act), or a rural emer24 gency hospital (as defined in section 1861(kkk) 

25 of the Social Security Act), together with any 


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1 parent, subsidiary, or other affiliated provider 

2 or supplier of health care items and services 

3 without regard to whether such parent, sub4 sidiary, or other affiliated provider or supplier 

5 operates under separate licensure, certification, 

6 or designation. 

7 ‘‘(D) PAYER-SPECIFIC NEGOTIATED

8 CHARGE.—The term ‘payer-specific negotiated 

9 charge’ means the charge that a hospital has 

10 negotiated with a third party payer for an item 

11 or service. 

12 ‘‘(E) SHOPPABLE SERVICE.—The term 

13 ‘shoppable service’ means a service that can be 

14 scheduled by a health care consumer in advance 

15 and includes all ancillary items and services 

16 customarily furnished as part of such service. 

17 ‘‘(F) THIRD PARTY PAYER.—The term 

18 ‘third party payer’ means an entity that is, by 

19 statute, contract, or agreement, legally respon20 sible for payment of a claim for a health care 

21 item or service.’’. 

22 (b) EFFECTIVE DATE.— 

23 (1) IN GENERAL.—The amendments made by 

24 subsection (a) shall apply beginning January 1, 

25 2025. 


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1 (2) CONTINUED APPLICABILITY OF RULES FOR

2 PREVIOUS YEARS.—Nothing in the amendments 

3 made by this section may be construed as affecting 

4 the applicability of the regulations codified at part 

5 180 of title 45, Code of Federal Regulations, before 

6 January 1, 2025. 

7 (c) CONTINUED APPLICABILITY OF STATE LAW.— 

8 The provisions of this Act shall not supersede any provi9 sion of State law that establishes, implements, or con10 tinues in effect any requirement or prohibition related to 

11 health care price transparency, except to the extent that 

12 such requirement or prohibition prevents the application 

13 of a requirement or prohibition of this Act. 

14 SEC. 3. INCREASING PRICE TRANSPARENCY OF CLINICAL 

15 DIAGNOSTIC LABORATORY TESTS UNDER 

16 THE MEDICARE PROGRAM. 

17 Section 2718 of the Public Health Service Act (42 

18 U.S.C. 300gg–18) is amended by adding at the end the 

19 following: 

20 ‘‘(f) CLINICAL DIAGNOSTIC LABORATORY PRICE

21 TRANSPARENCY.— 

22 ‘‘(1) IN GENERAL.—Beginning January 1, 

23 2025, any applicable laboratory that receives pay24 ment from a group health plan or health insurance 


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1 issuer for furnishing any specified clinical diagnostic 

2 laboratory test shall— 

3 ‘‘(A) make publicly available on an internet 

4 website the information described in paragraph 

5 (2) with respect to each such specified clinical 

6 diagnostic laboratory test that such laboratory 

7 so furnishes; and 

8 ‘‘(B) ensure that such information is up9 dated not less frequently than annually. 

10 ‘‘(2) INFORMATION DESCRIBED.—For purposes 

11 of paragraph (1), the information described in this 

12 paragraph is, with respect to an applicable labora13 tory and a specified clinical diagnostic laboratory 

14 test, the following: 

15 ‘‘(A) A plain language description of each 

16 item or service, accompanied by any applicable 

17 billing codes, including modifiers, using com18 monly recognized billing code sets, including the 

19 Current Procedural Terminology code, the 

20 Healthcare Common Procedure Coding System 

21 code, the diagnosis-related group, the National 

22 Drug Code, and other nationally recognized 

23 identifier. 


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1 ‘‘(B) The gross charge, as applicable, ex2 pressed as a dollar amount, for each such item 

3 or service. 

4 ‘‘(C) The discounted cash price, as applica5 ble, expressed as a dollar amount, for each such 

6 item or service (or, in the case no discounted 

7 cash price is available for an item or service, 

8 the minimum cash price accepted by the labora9 tory from self-pay individuals for such item or 

10 service when provided in such settings for the 

11 previous three years, expressed as a dollar 

12 amount, as well as, with respect to prices made 

13 public pursuant to subparagraph (A)(ii), a link 

14 to a consumer-friendly document that clearly 

15 explains the laboratory’s charity care policy). 

16 The laboratory shall accept the discounted cash 

17 price as payment in full from any patient that 

18 chooses to pay in cash without regard to the pa19 tient’s coverage. 

20 ‘‘(D) The payer-specific negotiated 

21 charges, expressed as a dollar amount and 

22 clearly associated with the name of the applica23 ble third party payer and name of each plan, 

24 that apply to each such item or service when 

25 provided in, as applicable, the inpatient setting 


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1 and outpatient department setting. If the 

2 charges are based on an algorithm, percentage 

3 of another amount, or other formula or criteria, 

4 the clinical diagnostic laboratory also shall dis5 close such algorithm, percentage, formula, or 

6 criteria as set forth in its contract and any 

7 other terms, schedules, exhibits, data, or other 

8 information referenced in any such contract as 

9 shall be required to determine and disclose the 

10 negotiated charge. 

11 ‘‘(E) The de-identified maximum and min12 imum negotiated charges, as applicable, for 

13 each such item or service, expressed as a non14 zero dollar amount. 

15 ‘‘(F) Any other additional information the 

16 Secretary may require for the purpose of im17 proving the accuracy of, or enabling consumers 

18 to easily understand and compare, standard 

19 charges and prices for an item or service, ex20 cept information that is duplicative of any other 

21 reporting requirement under this subsection. In 

22 the case of standard charges and prices for an 

23 item or service included as part of a bundled, 

24 per diem, episodic, or other similar arrange25 ment, the information described in this subVerDate Sep 11 2014 02:51 Jan 03, 2024 Jkt 049200 PO 00000 Frm 00019 Fmt 6652 Sfmt 6201 E:\BILLS\S3548.IS S3548

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1 paragraph shall be made available as deter2 mined appropriate by the Secretary. 

3 ‘‘(3) UNIFORM METHOD AND FORMAT.—Not 

4 later than January 1, 2025, the Secretary shall es5 tablish a standard, uniform method and format for 

6 applicable laboratories to use in compiling and mak7 ing public information pursuant to paragraph (1). 

8 Such method and format— 

9 ‘‘(A) shall include a machine-readable 

10 spreadsheet format containing the information 

11 described in paragraph (2) for all items and 

12 services furnished by each laboratory; 

13 ‘‘(B) may be similar to any template made 

14 available by the Centers for Medicare & Med15 icaid Services (as described in subsection (e)); 

16 ‘‘(C) shall meet such standards as deter17 mined appropriate by the Secretary in order to 

18 ensure the accessibility and usability of such in19 formation; and 

20 ‘‘(D) shall be updated as determined ap21 propriate by the Secretary, in consultation with 

22 stakeholders. 

23 ‘‘(4) INCLUSION OF ANCILLARY SERVICES.— 

24 Any price or rate for a specified clinical diagnostic 

25 laboratory test available to be furnished by an appliVerDate Sep 11 2014 02:51 Jan 03, 2024 Jkt 049200 PO 00000 Frm 00020 Fmt 6652 Sfmt 6201 E:\BILLS\S3548.IS S3548

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1 cable laboratory made publicly available in accord2 ance with paragraph (1) shall include the price or 

3 rate (as applicable) for any ancillary item or service 

4 (such as specimen collection services) that would 

5 normally be furnished by such laboratory as part of 

6 such test, as specified by the Secretary. 

7 ‘‘(5) ENFORCEMENT.— 

8 ‘‘(A) IN GENERAL.—In the case that the 

9 Secretary determines that an applicable labora10 tory is not in compliance with paragraph (1)— 

11 ‘‘(i) not later than 30 days after such 

12 determination, the Secretary shall notify 

13 such laboratory of such determination; and 

14 ‘‘(ii) if such laboratory continues to 

15 fail to comply with such paragraph after 

16 the date that is 90 days after such notifi17 cation is sent, the Secretary may impose a 

18 civil monetary penalty in an amount not to 

19 exceed $300 for each (beginning with the 

20 day on which the Secretary first deter21 mined that such laboratory was failing to 

22 comply with such paragraph) during which 

23 such failure is ongoing. 

24 ‘‘(B) INCREASE AUTHORITY.—In applying 

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1 ring in 2025 or a subsequent year, the Sec2 retary may through notice and comment rule3 making increase the per day limitation on civil 

4 monetary penalties under subparagraph (A)(ii). 

5 ‘‘(C) APPLICATION OF CERTAIN PROVI6 SIONS.—The provisions of section 1128A of the 

7 Social Security Act (other than subsections (a) 

8 and (b) of such section) shall apply to a civil 

9 monetary penalty imposed under this paragraph 

10 in the same manner as such provisions apply to 

11 a civil monetary penalty imposed under sub12 section (a) of such section. 

13 ‘‘(6) PROVISION OF TECHNICAL ASSISTANCE.— 

14 The Secretary shall, to the extent practicable, pro15 vide technical assistance relating to compliance with 

16 the provisions of this subsection to applicable labora17 tories requesting such assistance. 

18 ‘‘(7) DEFINITIONS.—In this subsection: 

19 ‘‘(A) APPLICABLE LABORATORY.—The 

20 term ‘applicable laboratory’ has the meaning 

21 given such term in section 414.502, of title 42, 

22 Code of Federal Regulations (or a successor 

23 regulation), except that such term does not in24 clude a laboratory with respect to which stand25 ard charges and prices for specified clinical diVerDate Sep 11 2014 02:51 Jan 03, 2024 Jkt 049200 PO 00000 Frm 00022 Fmt 6652 Sfmt 6201 E:\BILLS\S3548.IS S3548

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1 agnostic laboratory tests furnished by such lab2 oratory are made available by a hospital pursu3 ant to subsection (e). 

4 ‘‘(B) DISCOUNTED CASH PRICE.—The 

5 term ‘discounted cash price’ means the charge 

6 that applies to an individual who pays cash, or 

7 cash equivalent, for an item or service. 

8 ‘‘(C) GROSS CHARGE.—The term ‘gross 

9 charge’ means the charge for an individual item 

10 or service that is reflected on an applicable lab11 oratory’s chargemaster, absent any discounts. 

12 ‘‘(D) PAYER-SPECIFIC NEGOTIATED

13 CHARGE.—The term ‘payer-specific negotiated 

14 charge’ means the charge that an applicable 

15 laboratory has negotiated with a third party 

16 payer for an item or service. 

17 ‘‘(E) SPECIFIED CLINICAL DIAGNOSTIC

18 LABORATORY TEST.—The term ‘specified clin19 ical diagnostic laboratory test’ means a clinical 

20 diagnostic laboratory test that is included on 

21 the list of shoppable services specified by the 

22 Centers for Medicare & Medicaid Services (as 

23 described in subsection (e)), other than such a 

24 test that is only available to be furnished by a 

25 single provider of services or supplier. 


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1 ‘‘(F) THIRD PARTY PAYER.—The term 

2 ‘third party payer’ means an entity that is, by 

3 statute, contract, or agreement, legally respon4 sible for payment of a claim for a health care 

5 item or service.’’. 

6 SEC. 4. IMAGING TRANSPARENCY. 

7 Section 2718 of the Public Health Service Act (42 

8 U.S.C. 300gg–18), as amended by section 3, is further 

9 amended by adding at the end the following: 

10 ‘‘(g) IMAGING SERVICES PRICE TRANSPARENCY.— 

11 ‘‘(1) IN GENERAL.—Beginning January 1, 

12 2025, each provider of services and supplier that re13 ceives payment from a group health plan or health 

14 insurance issuer for furnishing a specified imaging 

15 service, other than such a provider or supplier with 

16 respect to which standard charges and prices for 

17 such services furnished by such provider or supplier 

18 are made available by a hospital pursuant to sub19 section (e), shall— 

20 ‘‘(A) make publicly available (in accord21 ance with paragraph (3)) on an internet website 

22 the information described in paragraph (2) with 

23 respect to each such service that such provider 

24 of services or supplier furnishes; and 


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1 ‘‘(B) ensure that such information is up2 dated not less frequently than annually. 

3 ‘‘(2) INFORMATION DESCRIBED.—For purposes 

4 of paragraph (1), the information described in this 

5 paragraph is, with respect to a provider of services 

6 or supplier and a specified imaging service, the fol7 lowing: 

8 ‘‘(A) A plain language description of each 

9 item or service, accompanied by any applicable 

10 billing codes, including modifiers, using com11 monly recognized billing code sets, including the 

12 Current Procedural Terminology code, the 

13 Healthcare Common Procedure Coding System 

14 code, the diagnosis-related group, the National 

15 Drug Code, and other nationally recognized 

16 identifier. 

17 ‘‘(B) The gross charge, as applicable, ex18 pressed as a dollar amount, for each such item 

19 or service. 

20 ‘‘(C) The discounted cash price, as applica21 ble, expressed as a dollar amount, for each such 

22 item or service (or, in the case no discounted 

23 cash price is available for an item or service, 

24 the minimum cash price accepted by the pro25 vider of services or supplier from self-pay indiVerDate Sep 11 2014 02:51 Jan 03, 2024 Jkt 049200 PO 00000 Frm 00025 Fmt 6652 Sfmt 6201 E:\BILLS\S3548.IS S3548

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1 viduals for such item or service when provided 

2 in such settings for the previous three years, ex3 pressed as a dollar amount, as well as, with re4 spect to prices made public pursuant to sub5 paragraph (A)(ii), a link to a consumer-friendly 

6 document that clearly explains the provider of 

7 services or supplier’s charity care policy). The 

8 provider of services or supplier shall accept the 

9 discounted cash price as payment in full from 

10 any patient that chooses to pay in cash without 

11 regard to the patient’s coverage. 

12 ‘‘(D) The payer-specific negotiated 

13 charges, expressed as a dollar amount and 

14 clearly associated with the name of the applica15 ble third party payer and name of each plan, 

16 that apply to each such item or service when 

17 provided in, as applicable, the inpatient setting 

18 and outpatient department setting. If the 

19 charges are based on an algorithm, percentage 

20 of another amount, or other formula or criteria, 

21 the provider or supplier also shall disclose such 

22 algorithm, percentage, formula, or criteria as 

23 set forth in its contract and any other terms, 

24 schedules, exhibits, data, or other information 

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1 quired to determine and disclose the negotiated 

2 charge. 

3 ‘‘(E) The de-identified maximum and min4 imum negotiated charges, as applicable, for 

5 each such item or service, expressed as a non6 zero dollar amount. 

7 ‘‘(F) Any other additional information the 

8 Secretary may require for the purpose of im9 proving the accuracy of, or enabling consumers 

10 to easily understand and compare, standard 

11 charges and prices for an item or service, ex12 cept information that is duplicative of any other 

13 reporting requirement under this subsection. In 

14 the case of standard charges and prices for an 

15 item or service included as part of a bundled, 

16 per diem, episodic, or other similar arrange17 ment, the information described in this sub18 paragraph shall be made available as deter19 mined appropriate by the Secretary. 

20 ‘‘(3) UNIFORM METHOD AND FORMAT.—Not 

21 later than January 1, 2025, the Secretary shall es22 tablish a standard, uniform method and format for 

23 providers of services and suppliers to use in making 

24 public information described in paragraph (2). Any 

25 such method and format— 


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1 ‘‘(A) shall include a machine-readable 

2 spreadsheet format containing the information 

3 described in paragraph (2) for all items and 

4 services furnished by each provider of services 

5 and supplier described in paragraph (1); 

6 ‘‘(B) may be similar to any template made 

7 available by the Centers for Medicare & Med8 icaid Services (as described in subsection (e)); 

9 ‘‘(C) shall meet such standards as deter10 mined appropriate by the Secretary in order to 

11 ensure the accessibility and usability of such in12 formation; and 

13 ‘‘(D) shall be updated as determined ap14 propriate by the Secretary, in consultation with 

15 stakeholders. 

16 ‘‘(4) MONITORING COMPLIANCE.—The Sec17 retary shall, through notice and comment rule18 making and in consultation with the Inspector Gen19 eral of the Department of Health and Human Serv20 ices, establish a process to monitor compliance with 

21 this subsection. 

22 ‘‘(5) ENFORCEMENT.— 

23 ‘‘(A) IN GENERAL.—In the case that the 

24 Secretary determines that a provider of services 


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1 or supplier is not in compliance with paragraph 

2 (1)— 

3 ‘‘(i) not later than 30 days after such 

4 determination, the Secretary shall notify 

5 such provider or supplier of such deter6 mination; 

7 ‘‘(ii) upon request of the Secretary, 

8 such provider or supplier shall submit to 

9 the Secretary, not later than 45 days after 

10 the date of such request, a corrective ac11 tion plan to comply with such paragraph; 

12 and 

13 ‘‘(iii) if such provider or supplier con14 tinues to fail to comply with such para15 graph after the date that is 90 days after 

16 such notification is sent (or, in the case of 

17 such a provider or supplier that has sub18 mitted a corrective action plan described in 

19 clause (ii) in response to a request so de20 scribed, after the date that is 90 days after 

21 such submission), the Secretary may im22 pose a civil monetary penalty in an amount 

23 not to exceed $300 for each day (beginning 

24 with the day on which the Secretary first 

25 determined that such provider or supplier 


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1 was failing to comply with such paragraph) 

2 during which such failure to comply or fail3 ure to submit is ongoing. 

4 ‘‘(B) INCREASE AUTHORITY.—In applying 

5 this paragraph with respect to violations occur6 ring in 2027 or a subsequent year, the Sec7 retary may through notice and comment rule8 making increase the amount of the civil mone9 tary penalty under subparagraph (A)(iii). 

10 ‘‘(C) APPLICATION OF CERTAIN PROVI11 SIONS.—The provisions of section 1128A of the 

12 Social Security Act (other than subsections (a) 

13 and (b) of such section) shall apply to a civil 

14 monetary penalty imposed under this paragraph 

15 in the same manner as such provisions apply to 

16 a civil monetary penalty imposed under sub17 section (a) of such section. 

18 ‘‘(D) NO AUTHORITY TO WAIVE OR RE19 DUCE PENALTY.—The Secretary shall not grant 

20 or extend any waiver, delay, tolling, or other 

21 mitigation of a civil monetary penalty for viola22 tion of this subsection. 

23 ‘‘(E) PROVISION OF TECHNICAL ASSIST24 ANCE.—The Secretary shall, to the extent prac25 ticable, provide technical assistance relating to 


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1 compliance with the provisions of this sub2 section to providers of services and suppliers re3 questing such assistance. 

4 ‘‘(F) CLARIFICATION OF NONAPPLICA5 BILITY OF OTHER ENFORCEMENT PROVI6 SIONS.—Notwithstanding any other provision of 

7 this title, this paragraph shall be the sole 

8 means of enforcing the provisions of this sub9 section. 

10 ‘‘(6) SPECIFIED IMAGING SERVICE DEFINED.— 

11 the term ‘specified imaging service’ means an imag12 ing service that is a Centers for Medicare & Med13 icaid Services-specified shoppable service (as de14 scribed in subsection (e)).’’. 

15 SEC. 5. AMBULATORY SURGICAL CENTER PRICE TRANS16 PARENCY REQUIREMENTS. 

17 Section 2718 of the Public Health Service Act (42 

18 U.S.C. 300gg–18), as amended by section 4, is further 

19 amended by adding at the end the following: 

20 ‘‘(h) AMBULATORY SURGERY CENTER TRANS21 PARENCY.— 

22 ‘‘(1) IN GENERAL.—Beginning January 1, 

23 2025, each specified ambulatory surgical center that 

24 receives payment from a group health plan or health 

25 insurance issuer for furnishing items and services 


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1 shall comply with the price transparency require2 ment described in paragraph (2). 

3 ‘‘(2) REQUIREMENT DESCRIBED.— 

4 ‘‘(A) IN GENERAL.—For purposes of para5 graph (1), the price transparency requirement 

6 described in this subsection is, with respect to 

7 a specified ambulatory surgical center, that 

8 such surgical center in accordance with a meth9 od and format established by the Secretary 

10 under subparagraph (C)), compile and make 

11 public (without subscription and free of 

12 charge), for each year— 

13 ‘‘(i) one or more lists, in a machine14 readable format specified by the Secretary, 

15 of the ambulatory surgical center’s stand16 ard charges (including the information de17 scribed in subparagraph (B)) for each item 

18 and service furnished by such surgical cen19 ter; 

20 ‘‘(ii) information in a consumer21 friendly format (as specified by the Sec22 retary) on the ambulatory surgical center’s 

23 prices (including the information described 

24 in subparagraph (B)) for as many of the 

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1 specified shoppable services included on the 

2 list described in subsection (e) that are 

3 furnished by such surgical center, and as 

4 many additional ambulatory surgical cen5 ter-selected shoppable services (or all such 

6 additional services, if such surgical center 

7 furnishes fewer than 300 shoppable serv8 ices) as may be necessary for a combined 

9 total of at least 300 shoppable services; 

10 and 

11 ‘‘(iii) with respect to each Centers for 

12 Medicare & Medicaid Services-specified 

13 shoppable service (as described in clause 

14 (ii)) that is not furnished by the ambula15 tory surgical center, an indication that 

16 such service is not so furnished. 

17 ‘‘(B) INFORMATION DESCRIBED.—For pur18 poses of subparagraph (A), the information de19 scribed in this subparagraph is, with respect to 

20 standard charges and prices, as applicable, 

21 made public by a specified ambulatory surgical 

22 center, the following: 

23 ‘‘(i) A description of each item or 

24 service, accompanied by, as applicable, the 

25 Healthcare Common Procedure Coding 


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1 System code, the national drug code, or 

2 other identifier used or approved by the 

3 Centers for Medicare & Medicaid 

4 Services. 

5 ‘‘(ii) The gross charge, expressed as a 

6 dollar amount, for each such item or serv7 ice. 

8 ‘‘(iii) The discounted cash price, ex9 pressed as a dollar amount, for each such 

10 item or service (or, in the case no dis11 counted cash price is available for an item 

12 or service, the minimum cash price accept13 ed by the specified ambulatory surgical 

14 center from self-pay individuals for such 

15 item or service when provided in such set16 tings for the previous three years, ex17 pressed as a dollar amount, as well as, 

18 with respect to prices made public pursu19 ant to subparagraph (A)(ii), a link to a 

20 consumer-friendly document that clearly 

21 explains the provider of services or sup22 plier’s charity care policy). The specified 

23 ambulatory surgical center shall accept the 

24 discounted cash price as payment in full 

25 from any patient that chooses to pay in 


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1 cash without regard to the patient’s cov2 erage. 

3 ‘‘(iv) The payer-specific negotiated 

4 charges, expressed as a dollar amount and 

5 clearly associated with the name of the ap6 plicable third party payer and name of 

7 each plan, that apply to each such item or 

8 service when provided in, as applicable, the 

9 inpatient setting and outpatient depart10 ment setting. If the charges are based on 

11 an algorithm, percentage of another 

12 amount, or other formula or criteria, the 

13 ambulatory surgical center also shall dis14 close such algorithm, percentage, formula, 

15 or criteria as set forth in its contract and 

16 any other terms, schedules, exhibits, data, 

17 or other information referenced in any 

18 such contract as shall be required to deter19 mine and disclose the negotiated charge. 

20 ‘‘(v) The de-identified maximum and 

21 minimum negotiated charges, as applica22 ble, for each such item or service, ex23 pressed as a non-zero dollar amount. 

24 ‘‘(vi) Any other additional information 

25 the Secretary may require for the purpose 


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1 of improving the accuracy of, or enabling 

2 consumers to easily understand and com3 pare, standard charges and prices for an 

4 item or service, except information that is 

5 duplicative of any other reporting require6 ment under this subsection. 

7 ‘‘(C) UNIFORM METHOD AND FORMAT.— 

8 Not later than January 1, 2025, the Secretary 

9 shall establish a standard, uniform method and 

10 format for specified ambulatory surgical centers 

11 to use in making public standard charges pur12 suant to subparagraph (A)(i) and a standard, 

13 uniform method and format for such centers to 

14 use in making public prices pursuant to sub15 paragraph (A)(ii). Any such method and for16 mat— 

17 ‘‘(i) shall, in the case of such charges 

18 made public by an ambulatory surgical 

19 center, ensure that such charges are made 

20 available in a machine-readable format; 

21 ‘‘(ii) may be similar to any template 

22 made available by the Centers for Medicare 

23 & Medicaid Services (as described in sub24 section (e)); 


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1 ‘‘(iii) shall meet such standards as de2 termined appropriate by the Secretary in 

3 order to ensure the accessibility and 

4 usability of such charges and prices; and 

5 ‘‘(iv) shall be updated as determined 

6 appropriate by the Secretary, in consulta7 tion with stakeholders. 

8 ‘‘(3) NO DEEMED COMPLIANCE.—The avail9 ability of a price estimator tool shall not be consid10 ered to deem compliance with or otherwise vitiate 

11 the requirements of this subsection (aa). Further12 more, the use of an estimator tool shall not be used 

13 for purposes of compliance with any provisions in 

14 this subsection. 

15 ‘‘(4) MONITORING COMPLIANCE.—The Sec16 retary shall, in consultation with the Inspector Gen17 eral of the Department of Health and Human Serv18 ices, establish a process to monitor compliance with 

19 this subsection. Such process shall ensure that each 

20 specified ambulatory surgical center’s compliance 

21 with this subsection is reviewed not less frequently 

22 than once every year. 

23 ‘‘(5) ENFORCEMENT.— 

24 ‘‘(A) IN GENERAL.—In the case of a speci25 fied ambulatory surgical center that fails to 


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1 comply with the requirements of this sub2 section— 

3 ‘‘(i) the Secretary shall notify such 

4 ambulatory surgical center of such failure 

5 not later than 30 days after the date on 

6 which the Secretary determines such fail7 ure exists; and 

8 ‘‘(ii) upon request of the Secretary, 

9 the ambulatory surgical center shall submit 

10 to the Secretary, not later than 45 days 

11 after the date of such request, a corrective 

12 action plan to comply with such require13 ments. 

14 ‘‘(B) CIVIL MONETARY PENALTY.— 

15 ‘‘(i) IN GENERAL.—A specified ambu16 latory surgical center that has received a 

17 notification under subparagraph (A)(i) and 

18 fails to comply with the requirements of 

19 this subsection by the date that is 90 days 

20 after such notification (or, in the case of 

21 an ambulatory surgical center that has 

22 submitted a corrective action plan de23 scribed in subparagraph (A)(ii) in response 

24 to a request so described, by the date that 

25 is 90 days after such submission) shall be 


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1 subject to a civil monetary penalty of an 

2 amount specified by the Secretary for each 

3 day (beginning with the day on which the 

4 Secretary first determined that such hos5 pital was not complying with such require6 ments) during which such failure is ongo7 ing (not to exceed $300 per day). 

8 ‘‘(ii) INCREASE AUTHORITY.—In ap9 plying this subparagraph with respect to 

10 violations occurring in 2027 or a subse11 quent year, the Secretary may through no12 tice and comment rulemaking increase the 

13 limitation on the per day amount of any 

14 penalty applicable to a specified ambula15 tory surgical center under clause (i). 

16 ‘‘(iii) APPLICATION OF CERTAIN PRO17 VISIONS.—The provisions of section 1128A 

18 of the Social Security Act (other than sub19 sections (a) and (b) of such section) shall 

20 apply to a civil monetary penalty imposed 

21 under this subparagraph in the same man22 ner as such provisions apply to a civil mon23 etary penalty imposed under subsection (a) 

24 of such section. 


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1 ‘‘(iv) NO AUTHORITY TO WAIVE OR

2 REDUCE PENALTY.—The Secretary shall 

3 not grant or extend any waiver, delay, toll4 ing, or other mitigation of a civil monetary 

5 penalty for violation of this subsection. 

6 ‘‘(6) PROVISION OF TECHNICAL ASSISTANCE.— 

7 The Secretary shall, to the extent practicable, pro8 vide technical assistance relating to compliance with 

9 the provisions of this subsection to specified ambula10 tory surgical centers requesting such assistance. 

11 ‘‘(7) DEFINITIONS.—For purposes of this sec12 tion: 

13 ‘‘(A) DISCOUNTED CASH PRICE.—The 

14 term ‘discounted cash price’ means the charge 

15 that applies to an individual who pays cash, or 

16 cash equivalent, for a item or service furnished 

17 by an ambulatory surgical center. 

18 ‘‘(B) GROSS CHARGE.—The term ‘gross 

19 charge’ means the charge for an individual item 

20 or service that is reflected on a specified sur21 gical center’s chargemaster, absent any dis22 counts. 

23 ‘‘(C) GROUP HEALTH PLAN; GROUP

24 HEALTH INSURANCE COVERAGE; INDIVIDUAL

25 HEALTH INSURANCE COVERAGE.—The terms 


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1 ‘group health plan’, ‘group health insurance 

2 coverage’, and ‘individual health insurance cov3 erage’ have the meaning given such terms in 

4 section 2791 of the Public Health Service Act. 

5 ‘‘(D) PAYER-SPECIFIC NEGOTIATED

6 CHARGE.—The term ‘payer-specific negotiated 

7 charge’ means the charge that a specified sur8 gical center has negotiated with a third party 

9 payer for an item or service. 

10 ‘‘(E) SHOPPABLE SERVICE.—The term 

11 ‘shoppable service’ means a service that can be 

12 scheduled by a health care consumer in advance 

13 and includes all ancillary items and services 

14 customarily furnished as part of such service. 

15 ‘‘(F) SPECIFIED AMBULATORY SURGICAL

16 CENTER.—The term ‘specified ambulatory sur17 gical center’ means an ambulatory surgical cen18 ter with respect to which a hospital (or any per19 son with an ownership or control interest (as 

20 defined in section 1124(a)(3) of the Social Se21 curity Act) in a hospital) is a person with an 

22 ownership or control interest (as so defined). 

23 ‘‘(G) THIRD PARTY PAYER.—The term 

24 ‘third party payer’ means an entity that is, by 

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1 sible for payment of a claim for a health care 

2 item or service.’’. 

3 SEC. 6. STRENGTHENING HEALTH COVERAGE TRANS4 PARENCY REQUIREMENTS. 

5 (a) TRANSPARENCY IN COVERAGE.—Section 

6 1311(e)(3)(C) of the Patient Protection and Affordable 

7 Care Act (42 U.S.C. 18031(e)(3)(C)) is amended— 

8 (1) by striking ‘‘The Exchange’’ and inserting 

9 the following: 

10 ‘‘(i) IN GENERAL.—The Exchange’’; 

11 (2) in clause (i), as inserted by paragraph (1)— 

12 (A) by striking ‘‘participating provider’’ 

13 and inserting ‘‘provider’’; 

14 (B) by inserting ‘‘shall include the infor15 mation specified in clause (ii) and’’ after ‘‘such 

16 information’’; 

17 (C) by striking ‘‘an Internet website’’ and 

18 inserting ‘‘a self-service tool that meets the re19 quirements of clause (iii)’’; and 

20 (D) by striking ‘‘and such other’’ and all 

21 that follows through the period and inserting 

22 ‘‘or, at the option such individual, through a 

23 paper or phone disclosure (as selected by such 

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1 vidual) that meets such requirements as the 

2 Secretary may specify.’’; and 

3 (3) by adding at the end the following new 

4 clauses: 

5 ‘‘(ii) SPECIFIED INFORMATION.—For 

6 purposes of clause (i), the information 

7 specified in this clause is, with respect to 

8 benefits available under a health plan for 

9 an item or service furnished by a health 

10 care provider, the following: 

11 ‘‘(I) If such provider is a partici12 pating provider with respect to such 

13 item or service, the in-network rate 

14 (as defined in subparagraph (F)) for 

15 such item or service. 

16 ‘‘(II) If such provider is not de17 scribed in subclause (I), the maximum 

18 allowed amount for such item or serv19 ice. 

20 ‘‘(III) The amount of cost shar21 ing (including deductibles, copay22 ments, and coinsurance) that the indi23 vidual will incur for such item or serv24 ice (which, in the case such item or 

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1 vider described in subclause (II), shall 

2 be calculated using the maximum 

3 amount described in such subclause). 

4 ‘‘(IV) The amount the individual 

5 has already accumulated with respect 

6 to any deductible or out of pocket 

7 maximum under the plan (broken 

8 down, in the case separate deductibles 

9 or maximums apply to separate indi10 viduals enrolled in the plan, by such 

11 separate deductibles or maximums, in 

12 addition to any cumulative deductible 

13 or maximum). 

14 ‘‘(V) In the case such plan im15 poses any frequency or volume limita16 tions with respect to such item or 

17 service (excluding medical necessity 

18 determinations), the amount that such 

19 individual has accrued towards such 

20 limitation with respect to such item or 

21 service. 

22 ‘‘(VI) Any prior authorization, 

23 concurrent review, step therapy, fail 

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1 ble to coverage of such item or service 

2 under such plan. 

3 ‘‘(iii) SELF-SERVICE TOOL.—For pur4 poses of clause (i), a self-service tool estab5 lished by a health plan meets the require6 ments of this clause if such tool— 

7 ‘‘(I) is based on an internet 

8 website; 

9 ‘‘(II) provides for real-time re10 sponses to requests described in such 

11 clause; 

12 ‘‘(III) is updated in a manner 

13 such that information provided 

14 through such tool is timely and accu15 rate; 

16 ‘‘(IV) allows such a request to be 

17 made with respect to an item or serv18 ice furnished by— 

19 ‘‘(aa) a specific provider 

20 that is a participating provider 

21 with respect to such item or serv22 ice; 

23 ‘‘(bb) all providers that are 

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1 spect to such plan and such item 

2 or service; or 

3 ‘‘(cc) a provider that is not 

4 described in item (bb); 

5 ‘‘(V) provides that such a request 

6 may be made with respect to an item 

7 or service through use of the billing 

8 code for such item or service or 

9 through use of a descriptive term for 

10 such item or service; and 

11 ‘‘(VI) holds a member harmless 

12 for the amount of any difference in 

13 excess of the amount of the individ14 ual’s responsibility generated by the 

15 self-service tool and the amount ulti16 mately billed or charged to the indi17 vidual.’’. 

18 (b) DISCLOSURE OF ADDITIONAL INFORMATION.— 

19 Section 1311(e)(3) of the Patient Protection and Afford20 able Care Act (42 U.S.C. 18031(e)(3)) is amended by add21 ing at the end the following new subparagraphs: 

22 ‘‘(E) RATE AND PAYMENT INFORMA23 TION.— 

24 ‘‘(i) IN GENERAL.—Not later than 

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1 after, each health plan shall submit to the 

2 Exchange, the Secretary, the State insur3 ance commissioner, and make available to 

4 the public, the rate and payment informa5 tion described in clause (ii) in accordance 

6 with clause (iii). 

7 ‘‘(ii) RATE AND PAYMENT INFORMA8 TION DESCRIBED.—For purposes of clause 

9 (i), the rate and payment information de10 scribed in this clause is, with respect to a 

11 health plan, the following: 

12 ‘‘(I) With respect to each item or 

13 service for which benefits are available 

14 under such plan (expressed as a dollar 

15 amount), including prescription drugs, 

16 identified by CPT, HCPCS, DRG, 

17 NDC, or other applicable nationally 

18 recognized identifier, including any 

19 applicable code modifiers, and accom20 panied by a brief description of the 

21 item or service, the in-network rate in 

22 effect as of the date of the submission 

23 of such information with each pro24 vider (identified by national provider 

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1 vider with respect to such item or 

2 service, other than such a rate in ef3 fect with a provider that has sub4 mitted no claims for such item or 

5 service to such plan. 

6 ‘‘(II) With respect to each drug 

7 (identified by National Drug Code, J8 code, or other commonly recognized 

9 billing code used for drugs) for which 

10 benefits are available under such plan: 

11 ‘‘(aa) The in-network rate 

12 (expressed as a dollar amount), 

13 including the individual and total 

14 amounts for any bundled rates, 

15 in effect as of the first day of the 

16 month in which such information 

17 is made public with each provider 

18 that is a participating provider 

19 with respect to such drug. 

20 ‘‘(bb) The historical net 

21 price paid by such plan (net of 

22 rebates, discounts, and price con23 cessions) (expressed as a dollar 

24 amount) for such drug dispensed 

25 or administered during the 90- 


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1 day period beginning 180 days 

2 before such date of submission to 

3 each provider that was a partici4 pating provider with respect to 

5 such drug, broken down by each 

6 such provider (identified by na7 tional provider identifier), other 

8 than such an amount paid to a 

9 provider that has submitted no 

10 claims for such drug to such 

11 plan. 

12 ‘‘(III) With respect to each item 

13 or service for which benefits are avail14 able under such plan (expressed as a 

15 dollar amount), identified by CPT, 

16 DRG, HCPCS, NDC, or other appli17 cable nationally recognized identifier, 

18 including any applicable code modi19 fiers, and accompanied by a brief de20 scription of the item or service, the 

21 amount billed or charged by the pro22 vider, and the amount allowed by the 

23 plan, for each such item or service 

24 furnished during the 90-day period 

25 beginning 180 days before such date 


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1 of submission by each provider that 

2 was not a participating provider with 

3 respect to such item or service, broken 

4 down by each such provider (identified 

5 by national provider identifier), other 

6 than items and services with respect 

7 to which no claims for such item or 

8 service were submitted to such plan 

9 during such period. 

10 ‘‘(iii) MANNER OF SUBMISSION.—Rate 

11 and payment information required to be 

12 submitted and made available under this 

13 subparagraph shall be so submitted and so 

14 made available as follows: 

15 ‘‘(I) Information shall be con16 tained in 3 separate machine-readable 

17 files corresponding to the information 

18 described in each of subclauses (I) 

19 through (III) of clause (ii) that meet 

20 such requirements as specified by the 

21 Secretary through rulemaking, in con22 sultation with the Secretaries of 

23 Labor and the Treasury to apply com24 parable requirements to group health 

25 plans and to entities providing benefit 


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1 management or other third-party ad2 ministration services on a contractual 

3 basis with a group health plan. 

4 ‘‘(II) Requirements specified by 

5 the Secretary through rulemaking 

6 shall ensure that: 

7 ‘‘(aa) Such files are limited 

8 to an appropriate size, are made 

9 available in a widely available 

10 format that allows for informa11 tion contained in such files to be 

12 compared across health plans, 

13 and are accessible to individuals 

14 at no cost and without the need 

15 to establish a user account or 

16 provider other credentials. 

17 ‘‘(bb) The rates, amounts, 

18 and prices to be disclosed include 

19 contractual terms containing cal20 culation formulae, pricing meth21 odologies, and other information 

22 necessary to determine the dollar 

23 value of reimbursement. 


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1 ‘‘(cc) Each such file includes 

2 each of the following data ele3 ments: 

4 ‘‘(AA) A numerical 

5 identifier for the group 

6 health plan and/or health in7 surance issuer (such as a 

8 Health Insurance Oversight 

9 System identifier). 

10 ‘‘(BB) A plain-language 

11 description of the item or 

12 service (including, for drugs, 

13 the proprietary and non14 proprietary name assigned). 

15 ‘‘(CC) The billing code, 

16 including any applicable 

17 modifiers, associated with 

18 such item or service, includ19 ing the Healthcare Common 

20 Procedure Coding System 

21 code, diagnosis-related 

22 group, national drug code, 

23 or other commonly recog24 nized code set. 


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1 ‘‘(DD) The place of 

2 service code. 

3 ‘‘(EE) The National 

4 Provider Identifier or pro5 vider Tax Identification 

6 Number. 

7 ‘‘(III) The rate and payment in8 formation disclosed under subclauses 

9 (I) through (III) of clause (ii) shall be 

10 separately delineated for each item or 

11 service, regardless of whether such 

12 item or service is reimbursed as a part 

13 of a bundle, episode, or other group14 ing of items and services. 

15 ‘‘(IV) An officer or executive of 

16 competent authority shall attest to the 

17 accuracy and completeness of infor18 mation submitted and made available 

19 under this subparagraph. Such attes20 tation shall be deemed material to 

21 payments from the Federal Govern22 ment received by the group health 

23 plan or health insurance issuer. 


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1 ‘‘(V) Regulations promulgated 

2 pursuant to this section shall provide 

3 that: 

4 ‘‘(aa) The Secretary shall 

5 audit the three machine-readable 

6 files required by subparagraph 

7 (E)(ii) posted by no fewer than 

8 20 group health plans or health 

9 insurance issuers. 

10 ‘‘(bb) The Secretary of 

11 Labor shall audit the three ma12 chine-readable files required by 

13 subparagraph (E)(ii) posted by 

14 no fewer than 200 group health 

15 plans or service providers fur16 nishing third-party administrator 

17 services to a group health plan. 

18 ‘‘(cc) Findings, conclusions, 

19 and enforcement actions taken 

20 based on audits of the machine21 readable files shall be reported 

22 annually to Congress no later 

23 than July 1 of the calendar year 

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1 dited. Such report to Congress 

2 shall be accessible to the public. 

3 ‘‘(iv) USER GUIDE.—Each health plan 

4 shall make available to the public instruc5 tions written in plain language explaining 

6 how individuals may search for information 

7 described in clause (ii) in files submitted in 

8 accordance with clause (iii). 

9 ‘‘(F) DEFINITIONS.—In this paragraph: 

10 ‘‘(i) PARTICIPATING PROVIDER.—The 

11 term ‘participating provider’ has the mean12 ing given such term in section 2799A–1 of 

13 the Public Health Service Act. 

14 ‘‘(ii) IN-NETWORK RATE.—The term 

15 ‘in-network rate’ means, with respect to a 

16 health plan and an item or service fur17 nished by a provider that is a participating 

18 provider with respect to such plan and 

19 item or service, the contracted rate in ef20 fect between such plan and such provider 

21 for such item or service. If the rate is 

22 based on an algorithm, percentage of an23 other amount, or other formula or criteria, 

24 the health plan also shall disclose such al25 gorithm, percentage, formula, or criteria as 


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1 set forth in its contract and any other 

2 terms, schedules, exhibits, data, or other 

3 information referenced in any such con4 tract as shall be required to determine and 

5 disclose the negotiated rate. 

6 ‘‘(G) APPLICABILITY TO ACCOUNTABLE

7 CARE ORGANIZATIONS.—An applicable ACO 

8 participating in the Medicare Shared Savings 

9 Program, as defined in Section 1899 of the So10 cial Security Act (42 U.S.C. § 1395jjj), shall be 

11 subject to the requirements of this paragraph 

12 as if such applicable ACO is a group health 

13 plan or health insurance issuer. 

14 ‘‘(H) ENFORCEMENT.—Each year, the 

15 Secretary shall audit the three machine-read16 able files required by subparagraph (E)(ii) post17 ed by no fewer than 20 group health plans or 

18 health insurance issuers.’’. 

19 (c) EFFECTIVE DATE.— 

20 (1) IN GENERAL.—The amendments made by 

21 subsection (a) shall apply beginning January 1, 

22 2025. 

23 (2) CONTINUED APPLICABILITY OF RULES FOR

24 PREVIOUS YEARS.—Nothing in the amendments 

25 made by this section may be construed as affecting 


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1 the applicability of the rule entitled ‘‘Transparency 

2 in Coverage’’ published by the Department of the 

3 Treasury, the Department of Labor, and the De4 partment of Health and Human Services on Novem5 ber 12, 2020 (85 Fed. Reg. 72158) before January 

6 1, 2025. 

7 SEC. 7. INCREASING GROUP HEALTH PLAN ACCESS TO 

8 HEALTH DATA. 

9 (a) GROUP HEALTH PLAN ACCESS TO INFORMA10 TION.— 

11 (1) IN GENERAL.—Paragraph (2) of section 

12 408(b) of the Employee Retirement Income Security 

13 Act of 1974 ( 29 U.S.C. 1108(b)) is amended by 

14 adding at the end the following new subparagraphs: 

15 ‘‘(C) No contract or arrangement for serv16 ices between a group health plan and any other 

17 entity, including a health care provider (includ18 ing a health care facility), network or associa19 tion of providers, service provider offering ac20 cess to a network of providers, third-party ad21 ministrator, or pharmacy benefit manager (col22 lectively, ‘Covered Service Providers’), is rea23 sonable within the meaning of this paragraph 

24 unless such contract or arrangement— 


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1 ‘‘(i) allows the responsible group 

2 health plan access to all claims and en3 counter information, and any documenta4 tion supporting claim payments, including, 

5 but not limited to, medical records and pol6 icy documents, or data described in section 

7 724(a)(1)(B) to— 

8 ‘‘(I) enable such entity to comply 

9 with the terms of the plan and any 

10 applicable law; and 

11 ‘‘(II) determine the accuracy or 

12 reasonableness of payment; and 

13 ‘‘(ii) does not— 

14 ‘‘(I) unreasonably limit or delay 

15 access to such information or data; 

16 ‘‘(II) limit the volume of claims 

17 and encounter information or data 

18 that the group health plan may access 

19 during an audit; 

20 ‘‘(III) limit the disclosure of pric21 ing terms for value-based payment ar22 rangements or capitated payment ar23 rangements, including— 

24 ‘‘(aa) payment calculations 

25 and formulas; 


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1 ‘‘(bb) quality measures; 

2 ‘‘(cc) contract terms; 

3 ‘‘(dd) payment amounts; 

4 ‘‘(ee) measurement periods 

5 for all incentives; and 

6 ‘‘(ff) other payment meth7 odologies used by an entity, in8 cluding a health care provider 

9 (including a health care facility), 

10 network or association of pro11 viders, service provider offering 

12 access to a network of providers, 

13 third-party administrator, or 

14 pharmacy benefit manager; 

15 ‘‘(IV) limit the disclosure of over16 payments and overpayment recovery 

17 terms; 

18 ‘‘(V) limit the right of the group 

19 health plan to select an auditor or de20 fine audit scope or frequency; 

21 ‘‘(VI) otherwise limit or unduly 

22 delay the group health plan from ac23 cessing claims and encounter informa24 tion or data in a daily batch. 


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1 ‘‘(VII) limit the disclosure of fees 

2 charged to the group health plan re3 lated to plan administration and 

4 claims processing, including renegoti5 ation fees, access fees, repricing fees, 

6 or enhanced review fees; 

7 ‘‘(VIII) limit the right of the 

8 group health plan to request action on 

9 any suspect claim payments; or 

10 ‘‘(IX) limit public disclosure of 

11 de-identified or aggregate information. 

12 ‘‘(D) PRIVACY REQUIREMENTS.—Covered 

13 Service Providers shall provide information 

14 under this paragraph in a manner consistent 

15 with the privacy and security regulations pro16 mulgated under the Health Insurance Port17 ability and Accountability Act (HIPAA). This 

18 subparagraph shall not be read to abridge or 

19 limit the disclosure requirements under this 

20 paragraph or to impose additional privacy or se21 curity requirements on Covered Service Pro22 viders or plan sponsors. 

23 ‘‘(E) DISCLOSURE AND REDISCLOSURE; 

24 LIMITATION TO BUSINESS ASSOCIATES.—A 

25 group health plan receiving information or data 


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1 under this paragraph may disclose such infor2 mation only to the entity from which the infor3 mation or data was received, the group health 

4 plan or plan sponsor to which the information 

5 or data pertains, or to that entity’s business as6 sociates as defined in section 160.103 of title 

7 45, Code of Federal Regulations, or as other8 wise permitted by the HIPAA Privacy Rule (45 

9 CFR parts 160 and 164, subparts A and E). 

10 ‘‘(F) DATA STANDARDS.—Information 

11 made available under this section shall conform 

12 to the following standards: 

13 ‘‘(i) Institutional, professional, and 

14 dental claims received from a healthcare 

15 provider shall be made available to the 

16 group health plan as ASC X12N 837 files. 

17 The files shall be unmodified copies of the 

18 files sent from the provider. In the event 

19 that paper claims are sent by the provider, 

20 they shall be converted to the ASC X12N 

21 837 electronic format. Files shall be acces22 sible to the plan at no cost to the group 

23 health plan. 

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1 tance advice (ERA) notices sent by a Cov2 ered Service Provider shall be made avail3 able to the group health plan as ASC 

4 X12N 835 files. The files shall be unmodi5 fied copies of the files sent by the Covered 

6 Service Provider to the healthcare pro7 vider. Files shall be accessible at no cost to 

8 the group health plan. 

9 ‘‘(iii) The contractual terms con10 taining calculation formulae, pricing meth11 odologies, and other information used to 

12 determine the dollar value of reimburse13 ment. 

14 ‘‘(iv) All non-claim costs shall be 

15 itemized and made available to the group 

16 health plan in real time through a web17 based portal, through an API, and through 

18 a downloadable CSV file.’’. 

19 (2) CIVIL ENFORCEMENT.— 

20 (A) IN GENERAL.—Subsection (c) of sec21 tion 502 of such Act (29 U.S.C. 1132) is 

22 amended by adding at the end the following 

23 new paragraph: ‘‘(13) In the case of an agree24 ment between a group health plan and a health 

25 care provider (including a health care facility), 


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1 network or association of providers, service pro2 vider offering access to a network of providers, 

3 third-party administrator, or pharmacy benefit 

4 manager, that violates the provisions of section 

5 724, the Secretary may assess a civil penalty 

6 against such provider, network or association, 

7 service provider offering access to a network of 

8 providers, third-party administrator, pharmacy 

9 benefit manager, or other service provider in 

10 the amount of $10,000 for each day during 

11 which such violation continues. Such penalty 

12 shall be in addition to other penalties as may 

13 be prescribed by law. 

14 (B) CONFORMING AMENDMENT.—Para15 graph (6) of section 502(a) of such Act is 

16 amended by striking ‘‘or (9)’’ and inserting 

17 ‘‘(9), or (13)’’. 

18 (3) EXISTING PROVISIONS VOID.—Section 410 

19 of such Act is amended by adding at the end the fol20 lowing: 

21 ‘‘(c) Any provision in an agreement or instrument 

22 shall be void as against public policy if such provision— 

23 ‘‘(1) unduly delays or limits a group health plan 

24 from accessing the claims and encounter information 

25 or data described in section 724(a)(1)(B); or 


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1 ‘‘(2) violates the requirements of section 

2 408(b)(2)(C).’’. 

3 (4) TECHNICAL AMENDMENT.—Clause (i) of 

4 section 408(b)(2)(B) of such Act is amended by 

5 striking ‘‘this clause’’ and inserting ‘‘this para6 graph’’. 

7 (b) UPDATED ATTESTATION FOR PRICE AND QUAL8 ITY INFORMATION.—Section 724(a)(3) of the Employee 

9 Retirement Income Security Act of 1974 (29 U.S.C. 

10 1185m(a)(3)) is amended to read as follows: 

11 ‘‘(3) ATTESTATION.— 

12 ‘‘(A) IN GENERAL.—Subject to subpara13 graph (C), the group health plan or health in14 surance issuer offering group health insurance 

15 coverage shall annually submit to the Secretary 

16 an attestation that such plan or issuer of such 

17 coverage is in compliance with the requirements 

18 of this subsection. Such attestation shall also 

19 include a statement verifying that— 

20 ‘‘(i) the information or data described 

21 under subparagraphs (A) and (B) of para22 graph (1) is available upon request and 

23 provided to the group health plan, the plan 

24 administrator, or the issuer in a timely 

25 manner; and 


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1 ‘‘(ii) there are no terms in the agree2 ment under such paragraph (1) that di3 rectly or indirectly restrict or unduly delay 

4 a group health plan, the plan adminis5 trator, or the issuer from auditing, review6 ing, or otherwise accessing such informa7 tion, except as permitted under section 

8 408(b)(2)(C). 

9 ‘‘(B) LIMITATION ON SUBMISSION.—Sub10 ject to clause (ii), a group health plan or issuer 

11 offering group health insurance coverage may 

12 not enter into an agreement with a third-party 

13 administrator or other service provider to sub14 mit the attestation required under subpara15 graph (A). 

16 ‘‘(C) EXCEPTION.—In the case of a group 

17 health plan or issuer offering group health in18 surance coverage that is unable to obtain the 

19 information or data needed to submit the attes20 tation required under subparagraph (A), such 

21 plan or issuer may submit a written statement 

22 in lieu of such attestation that includes— 

23 ‘‘(i) an explanation of why such plan 

24 or issuer was unsuccessful in obtaining 

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1 er such plan or issuer was limited or pre2 vented from auditing, reviewing, or other3 wise accessing such information or data; 

4 ‘‘(ii) a description of the efforts made 

5 by the group health plan to remove any 

6 gag clause provisions from the agreement 

7 under paragraph (1); and 

8 ‘‘(iii) a description of any response by 

9 the third-party administrator or other serv10 ice provider with respect to efforts to com11 ply with the attestation requirement under 

12 subparagraph (A).’’. 

13 (c) EFFECTIVE DATE.—The amendments made by 

14 subsections (a) and (b) shall apply with respect to a plan 

15 beginning with the first plan year that begins on or after 

16 the date that is 1 year after the date of enactment of this 

17 Act. 

18 SEC. 8. PREEMPTION ONLY IN EVENT OF CONFLICT. 

19 The provisions of sections 2 through 5 of this Act 

20 (including the amendments made by such sections) shall 

21 not supersede any provision of State law which establishes, 

22 implements, or continues in effect any requirement or pro23 hibition related to health care price transparency, except 

24 to the extent that such requirement or prohibition pre25 vents the application of a requirement or prohibition of 


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1 such sections (or amendment). Nothing in this section 

2 shall be construed to affect health plans established under 

3 the Employee Retirement Income Security Act of 1974. 

Æ 


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