I 

111TH CONGRESS 

2D SESSION H. R. 4803 

To ensure health care consumer and provider access to certain health benefits 

plan information and to amend title XIX of the Social Security Act 

to provide transparency in hospital price and quality information. 

IN THE HOUSE OF REPRESENTATIVES 

MARCH 10, 2010 

Mr. BARTON of Texas (for himself, Mr. GENE GREEN of Texas, Mr. BURGESS, and Mr. STUPAK) introduced the following bill; which was referred 

to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means and Oversight and Government Reform, for 

a period to be subsequently determined by the Speaker, in each case for 

consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To ensure health care consumer and provider access to certain health benefits plan information and to amend title 

XIX of the Social Security Act to provide transparency 

in hospital price and quality information. 

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 ‘‘Patients’ Right to 

5 Know Act’’. 


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1 SEC. 2. HEALTH BENEFITS PLAN INFORMATION TRANS2 PARENCY. 

3 (a) ENSURING CONSUMER AND PROVIDER ACCESS

4 TO HEALTH BENEFITS PLAN INFORMATION.— 

5 (1) IN GENERAL.—Each entity offering a health 

6 benefits plan (as defined in subsection (d)) shall 

7 make available to enrollees and potential enrollees of 

8 such plan the following information: 

9 (A) The items and services that are in10 cluded as part of the coverage offered by such 

11 plan and the items and services that are not so 

12 included. 

13 (B) An explicit and clear list of limitations 

14 and restrictions in the health insurance cov15 erage offered, along with a description of such 

16 limitations and restrictions. 

17 (C) A description of the process available 

18 for appealing coverage decisions made by such 

19 plan. 

20 (D) The number of appeals related to cov21 erage decisions made during the previous cal22 endar year and the outcomes of such appeals. 

23 (E) The amount of cost-sharing (including 

24 premiums, deductibles, copayments, co-insur25 ance, maximum possible annual out-of-pocket 

26 expenditure, and maximum possible lifetime 


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1 out-of-pocket expenditure) required by such 

2 plan. 

3 (F) The number of participating providers 

4 according to medical specialty type. 

5 (G) The extent to which a particular 

6 health care provider accepts coverage provided 

7 by such plan and the extent to which such a 

8 provider participates in the provider network of 

9 such plan. 

10 (H) The percentage of total expenditures 

11 made by such plan during the previous calendar 

12 year that are attributable to administrative 

13 costs and an explanation of all the assumptions 

14 and factors used to calculate such percentage. 

15 (I) The plan terms and conditions, claims 

16 payment policies and practices, periodic finan17 cial disclosure, data on enrollment and disen18 rollment, data on the number of claims denials, 

19 data on rating practices, information on cost20 sharing and payments with respect to in-net21 work and out-of-network coverage, and any 

22 other information determined by the Secretary 

23 of Health and Human Services to be beneficial 

24 to consumers or medical providers. 


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1 (J) Information the Secretary of Health 

2 and Human Services deems appropriate regard3 ing the amount of waste and fraud in the oper4 ations of such plan, efforts to address such 

5 waste and fraud, and the outcomes of such ef6 forts. 

7 The requirement under this paragraph (including 

8 subparagraph (H)) shall apply only to entities offer9 ing health benefits plans (as defined in subsection 

10 (d)). 

11 (2) OUT-OF-POCKET COST-SHARING TRANS12 PARENCY.— 

13 (A) IN GENERAL.—An entity offering a 

14 health benefits plan shall disclose, upon request 

15 of an enrollee of such plan, the amount of out16 of-pocket cost-sharing (including deductibles, 

17 copayments, and coinsurance) under such plan 

18 that the enrollee would be responsible for pay19 ing with respect to the furnishing of a specific 

20 item or service by a provider participating in 

21 such plan in a timely manner. At a minimum, 

22 such information shall be made available to the 

23 enrollee, upon request, prior to seeking care, 

24 and shall be provided in a manner that allows 


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1 such enrollee to compare providers based on 

2 such information. 

3 (B) HEALTH CARE QUALITY INFORMATION

4 TO BE DISCLOSED.—In disclosing information 

5 described in subparagraph (A), an entity offer6 ing a health benefits plan shall, to the extent 

7 practicable and appropriate, associate such in8 formation with any available risk-adjusted qual9 ity data measures. The Secretary may specify 

10 that such measures include those that have 

11 been endorsed by the National Quality Forum. 

12 (3) ADVANCE NOTICE OF PLAN CHANGES.—An 

13 entity offering a health benefits plan shall not make 

14 a change to such plan without reasonable and timely 

15 advance notice of such change to enrollees of such 

16 plan. 

17 (4) CONTRACTING REIMBURSEMENT TRANS18 PARENCY.—An entity offering a health benefits plan 

19 shall disclose to each health care provider informa20 tion relating to the reimbursement arrangements be21 tween such plan and such provider. 

22 (b) ADMINISTRATIVE PROVISIONS AND INFORMATION

23 DESIGN.— 

24 (1) TIMELY DISCLOSURE AND UPDATES; ADDI25 TIONAL INFORMATION DISCLOSURES.— 


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1 (A) TIMELY DISCLOSURE AND UPDATES.— 

2 Each entity offering a health benefits plan shall 

3 provide for timely access to information de4 scribed in subsection (a) and consistent with 

5 such subsection, including through an Internet 

6 website. Such information shall first be made 

7 available not later than 18 months after the 

8 date of the enactment of this Act. Such infor9 mation shall be updated as often as is deemed 

10 feasible by the Secretary of Health and Human 

11 Services, but not less than once a calendar 

12 quarter. 

13 (B) ADDITIONAL INFORMATION DISCLO14 SURES.—The Secretary may undertake rule15 making as necessary in order to ensure that ad16 ditional information, as specified by the Sec17 retary, is progressively made available by enti18 ties offering health benefits plans, in order to 

19 provide for the maximum feasible reporting of 

20 information to meet the needs of consumers and 

21 providers of health care in making determina22 tions with regard to health care items, insur23 ance, and services. In no case shall such addi24 tional information be required to be made avail25 able by any entity other than an entity offering 


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1 a health benefits plan (as defined in subsection 

2 (d)). 

3 (2) INFORMATION DESIGN.— 

4 (A) IN GENERAL.—Each entity offering a 

5 health benefits plan shall ensure that the infor6 mation described in paragraph (1) is made 

7 available in a manner that— 

8 (i) is in a format that is easily acces9 sible, useable, and understandable to en10 rollees and potential enrollees of the plan 

11 as well as health care providers as applica12 ble; 

13 (ii) uses language that the intended 

14 audience can readily understand and that 

15 is clean, concise, well-organized, and fol16 lows other best practices of language writ17 ing; and 

18 (iii) to the greatest extent feasible, 

19 permits an individual to search the infor20 mation by a user-defined geographic area, 

21 such as within a 50-mile radius of the 

22 user’s home address. 

23 (B) ENABLING CONSUMERS TO COMPARE

24 INFORMATION.—The Secretary of Health and 

25 Human Services shall, by final rule issued not 


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1 later than 12 months after the date of the en2 actment of this Act, require entities offering 

3 health benefits plans to disclose the information 

4 described in subsection (a)(1) in such a format 

5 as to allow individuals to compare the coverage 

6 options available to them in as uniform a man7 ner as possible. 

8 (c) PENALTY.—The Secretary shall provide for a 

9 methodology to impose a penalty fee against each entity 

10 offering a health benefits plan that fails to substantially 

11 meet the requirements of subsections (a) and (b). Such 

12 methodology shall— 

13 (1) provide for an increased penalty amount in 

14 the case of such an entity that knowingly misrepre15 sents information required to be disclosed under 

16 subsection (a) or under regulations issued pursuant 

17 to subsection (b)(1)(B); 

18 (2) vary the amount of such fee based on the 

19 size of the entity involved and type of infraction. 

20 The provisions of section 1128A (other than subsections 

21 (a) and (b)) shall apply to a penalty fee imposed under 

22 this subsection in the same manner as such provisions 

23 apply to a penalty or proceeding under section 1128A(a). 

24 (d) ENTITY OFFERING A HEALTH BENEFITS PLAN

25 DEFINED.—For the purposes of this section, the term 


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1 ‘‘entity offering a health benefits plan’’ means a health 

2 insurance issuer with respect to the offering of health in3 surance coverage, including in the individual market and 

4 small and large group market (as such terms are defined 

5 in section 2791 of the Public Health Service Act); a plan 

6 sponsor with respect to the offering of a group health plan 

7 (as defined in such section 2791); and entities responsible 

8 for the administration of governmental health plans (in9 cluding the Centers for Medicare & Medicaid Services with 

10 respect to the Medicare program under title XVIII of the 

11 Social Security Act, State agencies responsible for admin12 istration of State plans under the Medicaid program under 

13 title XIX of such Act or State child assistance plans under 

14 the State Children’s Health Insurance Program under 

15 title XXI of such Act, and the Office of Personnel Man16 agement with respect to the Federal Employees Health 

17 Benefits Program under chapter 89 of title 5, United 

18 States Code). 

19 SEC. 3. HOSPITAL AND AMBULATORY SURGICAL CENTER 

20 PRICE AND QUALITY TRANSPARENCY. 

21 (a) IN GENERAL.—Section 1902(a) of the Social Se22 curity Act (42 U.S.C. 1396a(a)) is amended— 

23 (1) by striking ‘‘and’’ at the end of paragraph 

24 (72); 


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1 (2) by striking the period at the end of para2 graph (73) and inserting ‘‘; and’’; 

3 (3) by inserting after paragraph (73) the fol4 lowing new paragraph: 

5 ‘‘(74) provide that the State will establish and 

6 maintain laws, in accordance with the requirements 

7 of section 1921A, to require disclosure of informa8 tion on hospital and ambulatory surgical center 

9 charges and quality, to make such information avail10 able to the public and the Secretary.’’; and 

11 (4) by inserting after section 1921 the following 

12 new section: 

13 ‘‘SEC. 1921A. PRICE AND QUALITY TRANSPARENCY. 

14 ‘‘(a) IN GENERAL.—The requirements referred to in 

15 section 1902(a)(74) are that the laws of a State must— 

16 ‘‘(1) require reporting to a State (or its agent) 

17 by each hospital located therein, of information on— 

18 ‘‘(A) the charges for inpatient and out19 patient services typically performed (as defined 

20 by the Secretary through notice and comment 

21 rulemaking) by such hospital; 

22 ‘‘(B) the reimbursement amount under 

23 title XVIII and under the State plan under this 

24 title for such services; and 


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1 ‘‘(C) if the hospital allows for or provides 

2 reduced charges for individuals based on finan3 cial need, the factors considered in making de4 terminations for reductions in charges, includ5 ing any formula for such determination and the 

6 contact information for the specific department 

7 of a hospital that responds to such inquiries; 

8 ‘‘(2) provide for notice to individuals seeking or 

9 requiring such services of the availability of informa10 tion on charges described in paragraph (1); 

11 ‘‘(3) provide for timely access to such informa12 tion, including at least through an Internet website, 

13 by individuals seeking or requiring such services; 

14 and 

15 ‘‘(4) provide for timely access to information re16 garding the quality of care at each hospital made 

17 publicly available in accordance with section 501 of 

18 the Medicare Prescription Drug, Improvement, and 

19 Modernization Act of 2003, section 1139A, or sec20 tion 1139B. 

21 ‘‘(b) APPLICATION TO AMBULATORY SURGICAL CEN22 TERS.—The requirements described in subsection (a) shall 

23 apply, to the greatest extent practicable, to ambulatory 

24 surgical centers in the same manner as such requirements 

25 apply to hospitals, except that in applying paragraph (4) 


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1 of such subsection, the references described in such para2 graph shall be deemed to be a reference to section 

3 1833(i)(7). 

4 ‘‘(c) CONSULTATION WITH STAKEHOLDERS.—For 

5 purposes of carrying out this section, the Secretary shall 

6 consult with appropriate stakeholders through a formal 

7 process to obtain guidance prior to issuing any imple8 menting policies. 

9 ‘‘(d) HOSPITAL DEFINED.—For the purposes of this 

10 section, the term ‘hospital’ means an institution that 

11 meets the requirements of paragraphs (1) and (7) of sec12 tion 1861(e) and includes an institution to which section 

13 1820(c) applies. 

14 ‘‘(e) AMBULATORY SURGICAL CENTER DEFINED.— 

15 For purposes of this section, the term ‘ambulatory sur16 gical center’ means a center described in section 

17 1832(a)(2)(F)(i).’’ 

18 (b) EFFECTIVE DATE.— 

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

20 subsection (a) shall apply to State plans beginning 

21 not later than 2 years after the date of the enact22 ment of this Act. 

23 (2) EXISTING PROGRAMS.—The Secretary of 

24 Health and Human Services shall establish a process 

25 by which a State with an existing program may cerVerDate Nov 24 2008 16:44 Mar 11, 2010 Jkt 089200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\H4803.IH H4803

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1 tify to the Secretary that its program satisfies the 

2 requirements of section 1921A of the Social Security 

3 Act, as inserted by subsection (a). 

Æ 


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