II 

118TH CONGRESS 

1ST SESSION S. 1130 

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

price transparency. 

IN THE SENATE OF THE UNITED STATES 

MARCH 30, 2023 

Mr. BRAUN (for himself and Mr. GRASSLEY) 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’’. 


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1 SEC. 2. PRICE TRANSPARENCY REQUIREMENTS. 

2 (a) HOSPITALS.—Section 2718(e) of the Public 

3 Health Service Act (42 U.S.C. 300gg–18(e)) is amend4 ed— 

5 (1) by striking ‘‘Each hospital’’ and inserting 

6 the following: 

7 ‘‘(1) IN GENERAL.—Each hospital’’; 

8 (2) by inserting ‘‘, in plain language without 

9 subscription and free of charge, in a consumer10 friendly, machine-readable format,’’ after ‘‘a list’’; 

11 and 

12 (3) by adding at the end the following: ‘‘Each 

13 hospital shall include in its list of standard charges, 

14 along with such additional information as the Sec15 retary may require with respect to such charges for 

16 purposes of promoting public awareness of hospital 

17 pricing in advance of receiving a hospital item or 

18 service, as applicable, the following: 

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

20 service provided by the hospital. 

21 ‘‘(ii) The gross charge. 

22 ‘‘(iii) Any payer-specific negotiated 

23 charge clearly associated with the name of 

24 the third party payer and plan. 

25 ‘‘(iv) The de-identified minimum ne26 gotiated charge. 


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1 ‘‘(v) The de-identified maximum nego2 tiated charge. 

3 ‘‘(vi) The discounted cash price. 

4 ‘‘(vii) Any code used by the hospital 

5 for purposes of accounting or billing, in6 cluding Current Procedural Terminology 

7 (CPT) code, the Healthcare Common Pro8 cedure Coding System (HCPCS) code, the 

9 Diagnosis Related Group (DRG), the Na10 tional Drug Code (NDC), or other common 

11 payer identifier. 

12 ‘‘(2) DELIVERY METHODS AND USE.— 

13 ‘‘(A) IN GENERAL.—Each hospital shall 

14 make public the standard charges described in 

15 paragraph (1) for as many of the 70 Centers 

16 for Medicaid & Medicare Services-specified 

17 shoppable services that are provided by the hos18 pital, and as many additional hospital-selected 

19 shoppable services as may be necessary for a 

20 combined total of at least 300 shoppable serv21 ices, including the rate at which a hospital pro22 vides and bills for that shoppable service. If a 

23 hospital does not provide 300 shoppable services 

24 in accordance with the previous sentence, the 

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1 ified under paragraph (1) for as many 

2 shoppable services as it provides. 

3 ‘‘(B) DETERMINATION BY CMS.—A hos4 pital shall be deemed by the Centers for Medi5 care & Medicaid Services to meet the require6 ments of subparagraph (A) if the hospital main7 tains an internet-based price estimator tool that 

8 meets the following requirements: 

9 ‘‘(i) The tool provides estimates for as 

10 many of the 70 specified shoppable services 

11 that are provided by the hospital, and as 

12 many additional hospital-selected 

13 shoppable services as may be necessary for 

14 a combined total of at least 300 shoppable 

15 services. 

16 ‘‘(ii) The tool allows health care con17 sumers to, at the time they use the tool, 

18 obtain an estimate of the amount they will 

19 be obligated to pay the hospital for the 

20 shoppable service. 

21 ‘‘(iii) The tool is prominently dis22 played on the hospital’s website and easily 

23 accessible to the public, without subscrip24 tion, fee, or having to submit personal 

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1 able by service description, billing code, 

2 and payer. 

3 ‘‘(3) DEFINITIONS.—Notwithstanding any other 

4 provision of law, for the purpose of paragraphs (1) 

5 and (2): 

6 ‘‘(A) DE-IDENTIFIED MAXIMUM NEGO7 TIATED CHARGE.—The term ‘de-identified max8 imum negotiated charge’ means the highest 

9 charge that a hospital has negotiated with all 

10 third party payers for an item or service. 

11 ‘‘(B) DE-IDENTIFIED MINIMUM NEGO12 TIATED CHARGE.—The term ‘de-identified min13 imum negotiated charge’ means the lowest 

14 charge that a hospital has negotiated with all 

15 third party payers for an item or service. 

16 ‘‘(C) DISCOUNTED CASH PRICE.—The 

17 term ‘discounted cash price’ means the charge 

18 that applies to an individual who pays cash, or 

19 cash equivalent, for a hospital item or service. 

20 Hospitals that do not offer self-pay discounts 

21 may display the hospital’s undiscounted gross 

22 charges as found in the hospital chargemaster. 

23 ‘‘(D) GROSS CHARGE.—The term ‘gross 

24 charge’ means the charge for an individual item 


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1 or service that is reflected on a hospital’s 

2 chargemaster, absent any discounts. 

3 ‘‘(E) PAYER-SPECIFIC NEGOTIATED

4 CHARGE.—The term ‘payer-specific negotiated 

5 charge’ means the charge that a hospital has 

6 negotiated with a third party payer for an item 

7 or service. 

8 ‘‘(F) SHOPPABLE SERVICE.—The term 

9 ‘shoppable service’ means a service that can be 

10 scheduled by a health care consumer in ad11 vance. 

12 ‘‘(G) STANDARD CHARGES.—The term 

13 ‘standard charges’ means the regular rate es14 tablished by the hospital for an item or service, 

15 including both individual items and services and 

16 service packages, provided to a specific group of 

17 paying patients, including the gross charge, the 

18 payer-specific negotiated charge, the discounted 

19 cash price, the de-identified minimum nego20 tiated charge, the de-identified maximum nego21 tiated charge, and other rates determined by 

22 the Secretary. 

23 ‘‘(H) 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 ‘‘(4) ENFORCEMENT.—In addition to any other 

4 enforcement actions or penalties that may apply 

5 under subsection (b)(3) or another provision of law, 

6 a hospital that fails to provide the information re7 quired by this subsection and has not completed a 

8 corrective action plan to comply with the require9 ments of such subsection shall be subject to a civil 

10 monetary penalty of an amount not to exceed $300 

11 per day that the violation is ongoing as determined 

12 by the Secretary. Such penalty shall be imposed and 

13 collected in the same manner as civil money pen14 alties under subsection (a) of section 1128A of the 

15 Social Security Act are imposed and collected.’’. 

16 (b) TRANSPARENCY IN COVERAGE.—Section 

17 1311(e)(3) of the Patient Protection and Affordable Care 

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

19 (1) in subparagraph (A)— 

20 (A) by redesignating clause (ix) as clause 

21 (xii); and 

22 (B) by inserting after clause (viii), the fol23 lowing: 

24 ‘‘(ix) In-network provider rates for 

25 covered items and services. 


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1 ‘‘(x) Out-of-network allowed amounts 

2 and billed charges for covered items and 

3 services. 

4 ‘‘(xi) Negotiated rates and historical 

5 net prices for covered prescription drugs.’’; 

6 (2) in subparagraph (B)— 

7 (A) in the heading, by striking ‘‘USE’’ and 

8 inserting ‘‘DELIVERY METHODS AND USE’’; 

9 (B) by inserting ‘‘and subparagraph (C)’’ 

10 after ‘‘subparagraph (A)’’; 

11 (C) by inserting ‘‘, as applicable,’’ after 

12 ‘‘English proficiency’’; and 

13 (D) by inserting after the second sentence, 

14 the following: ‘‘The Secretary shall establish 

15 standards for the methods and formats for dis16 closing information to individuals. At a min17 imum, these standards shall include the fol18 lowing: 

19 ‘‘(i) An internet-based self-service tool 

20 to provide information to an individual in 

21 plain language, without subscription and 

22 free of charge, in a machine readable for23 mat, through a self-service tool on an 

24 internet website that provides real-time re25 sponses based on cost-sharing information 


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1 that is accurate at the time of the request 

2 that allows, at a minimum, users to— 

3 ‘‘(I) search for cost-sharing infor4 mation for a covered item or service 

5 provided by a specific in-network pro6 vider or by all in-network providers; 

7 ‘‘(II) search for an out-of-net8 work allowed amount, percentage of 

9 billed charges, or other rate that pro10 vides a reasonably accurate estimate 

11 of the amount an insurer will pay for 

12 a covered item or service provided by 

13 out-of-network providers; and 

14 ‘‘(III) refine and reorder search 

15 results based on geographic proximity 

16 of in-network providers, and the 

17 amount of the individual’s cost-shar18 ing liability for the covered item or 

19 service, to the extent the search for 

20 cost-sharing information for covered 

21 items or services returns multiple re22 sults. 

23 ‘‘(ii) In paper form at the request of 

24 the individual that includes no fewer than 

25 20 providers per request with respect to 


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1 which cost-sharing information for covered 

2 items and services is provided, and dis3 closes the applicable provider per-request 

4 limit to the individual, mailed to the indi5 vidual not later than 2 business days after 

6 receiving an individual’s request.’’; 

7 (3) in subparagraph (C)— 

8 (A) in the first sentence— 

9 (i) by striking ‘‘The Exchange’’ and 

10 inserting the following: 

11 ‘‘(i) IN GENERAL.—The Exchange’’; 

12 (ii) by inserting ‘‘or out-of-network 

13 provider’’ after ‘‘item or service by a par14 ticipating provider’’; and 

15 (iii) by inserting before the period the 

16 following: ‘‘the following information: 

17 ‘‘(i) An estimate of an individual’s 

18 cost-sharing liability for a requested cov19 ered item or service furnished by a pro20 vider, which shall reflect any cost-sharing 

21 reductions the individual would receive. 

22 ‘‘(ii) A description of the accumulated 

23 amounts. 


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1 ‘‘(iii) The in-network rate, including 

2 negotiated rates and underlying fee sched3 ule rates. 

4 ‘‘(iv) The out-of-network allowed 

5 amount or any other rate that provides a 

6 more accurate estimate of an amount an 

7 issuer will pay, including the percent reim8 bursed by insurers to out-of-network pro9 viders, for the requested covered item or 

10 service furnished by an out-of-network pro11 vider. 

12 ‘‘(v) A list of the items and services 

13 included in bundled payment arrangements 

14 for which cost-sharing information is being 

15 disclosed. 

16 ‘‘(vi) A notification that coverage of a 

17 specific item or service is subject to a pre18 requisite, if applicable. 

19 ‘‘(vii) A notice that includes the fol20 lowing information: 

21 ‘‘(I) A statement that out-of-net22 work providers may bill individuals for 

23 the difference, including the balance 

24 billing, between a provider’s billed 

25 charges and the sum of the amount 


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1 collected from the insurer in the form 

2 of a copayment or coinsurance 

3 amount and the cost-sharing informa4 tion. 

5 ‘‘(II) A statement that the actual 

6 charges for an individual’s covered 

7 item or service may be different from 

8 an estimate of cost-sharing liability 

9 depending on the actual items or serv10 ices the individual receives at the 

11 point of care. 

12 ‘‘(III) A statement that the esti13 mate of cost-sharing liability for a 

14 covered item or service is not a guar15 antee that benefits will be provided 

16 for that item or service. 

17 ‘‘(IV) A statement disclosing 

18 whether the plan counts copayment 

19 assistance and other third-party pay20 ments in the calculation of the indi21 vidual’s deductible and out-of-pocket 

22 maximum. 

23 ‘‘(V) For items and services that 

24 are recommended preventive services 

25 under section 2713 of the Public 


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1 Health Service Act, a statement that 

2 an in-network item or service may not 

3 be subject to cost-sharing if it is billed 

4 as a preventive service in the insurer 

5 cannot determine whether the request 

6 is for a preventive or non-preventive 

7 item or service. 

8 ‘‘(VI) Any additional informa9 tion, including other disclaimers, that 

10 the insurer determines is appropriate, 

11 provided the additional information 

12 does not conflict with the information 

13 required to be provided by this sub14 section.’’; 

15 (B) by striking the second sentence; and 

16 (C) by adding at the end the following: 

17 ‘‘(ii) DEFINITIONS.—Notwithstanding 

18 any other provision of law, for the purpose 

19 of subparagraphs (A), (B), and (C): 

20 ‘‘(I) ACCUMULATED AMOUNTS.— 

21 The term ‘accumulated amounts’ 

22 means the amount of financial respon23 sibility an individual has incurred at 

24 the time a request for cost-sharing in25 formation is made, with respect to a 


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1 deductible or out-of-pocket limit, in2 cluding any expense that counts to3 ward a deductible or out-of-pocket 

4 limit, but exclude any expense that 

5 does not count toward a deductible or 

6 out-of-pocket limit. To the extent an 

7 insurer imposes a cumulative treat8 ment limitation on a particular cov9 ered item or service independent of in10 dividual medical necessity determina11 tions, the amount that has accrued to12 ward the limit on the item or service. 

13 ‘‘(II) HISTORICAL NET PRICE.— 

14 The term ‘historical net price’ means 

15 the retrospective average amount an 

16 insurer paid for a prescription drug, 

17 inclusive of any reasonably allocated 

18 rebates, discounts, chargebacks, fees, 

19 and any additional price concessions 

20 received by the insurer with respect to 

21 the prescription drug. The allocation 

22 shall be determined by dollar value for 

23 non-product specific and product-spe24 cific rebates, discounts, chargebacks, 

25 fees, and other price concessions to 


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1 the extent that the total amount of 

2 any such price concession is known to 

3 the insurer at the time of publication 

4 of the historical net price. 

5 ‘‘(III) NEGOTIATED RATE.—The 

6 term ‘negotiated rate’ means the 

7 amount a plan or issuer has contrac8 tually agreed to pay for a covered 

9 item or service, whether directly or in10 directly through a third party admin11 istrator or pharmacy benefit manager, 

12 to an in-network provider, including 

13 an in-network pharmacy or other pre14 scription drug dispenser, for covered 

15 items or services. 

16 ‘‘(IV) OUT-OF-NETWORK AL17 LOWED AMOUNT.—The term ‘out-of18 network allowed amount’ means the 

19 maximum amount an insurer will pay 

20 for a covered item or service furnished 

21 by an out-of-network provider. 

22 ‘‘(V) OUT-OF-NETWORK LIMIT.— 

23 The term ‘out-of-network limit’ means 

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1 erage period for his or her share of 

2 the costs of covered items and services 

3 under his or her plan or coverage, in4 cluding for self-only and other than 

5 self-only coverage, as applicable. 

6 ‘‘(VI) UNDERLYING FEE SCHED7 ULE RATES.—The term ‘underlying 

8 fee schedule rates’ means the rate for 

9 an item or service that a plan or 

10 issuer uses to determine a partici11 pant’s, beneficiary’s, or enrollee’s 

12 cost-sharing liability from a particular 

13 provider or providers, when the rate is 

14 different from the negotiated rate.’’; 

15 (4) in subparagraph (D), by striking ‘‘subpara16 graph (A)’’ and inserting ‘‘subparagraphs (A), (B), 

17 and (C)’’; and 

18 (5) by adding at the end the following: 

19 ‘‘(F) APPLICATION OF PARAGRAPH.—In 

20 addition to qualified health plans (and plans 

21 seeking certification as qualified health plans), 

22 this paragraph (as amended by the Health Care 

23 Prices Revealed and Information to Consumers 

24 Explained Transparency Act) shall apply to 

25 group health plans (including self-insured and 


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1 fully insured plans) and health insurance cov2 erage (as such terms are defined in section 

3 2791 of the Public Health Service Act).’’. 

Æ 


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