I 

118TH CONGRESS 

1ST SESSION H. R. 4905 

To amend the Internal Revenue Code of 1986, the Public Health Service 

Act, and the Employee Retirement Income Security Act of 1974 to 

promote group health plan price transparency. 

IN THE HOUSE OF REPRESENTATIVES 

JULY 26, 2023 

Mr. FITZPATRICK (for himself and Ms. LEE of Nevada) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Education and the Workforce, and Ways and Means, 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 amend the Internal Revenue Code of 1986, the Public 

Health Service Act, and the Employee Retirement Income Security Act of 1974 to promote group health 

plan 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 Insurance Price 

5 Transparency Act of 2023’’. 


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1 SEC. 2. PROMOTING GROUP HEALTH PLAN PRICE TRANS2 PARENCY. 

3 (a) PRICE TRANSPARENCY REQUIREMENTS.— 

4 (1) IRC.— 

5 (A) IN GENERAL.—Section 9819 of the In6 ternal Revenue Code of 1986 (26 U.S.C. 9816) 

7 is amended to read as follows: 

8 ‘‘SEC. 9819. PRICE TRANSPARENCY REQUIREMENTS. 

9 ‘‘(a) COST SHARING TRANSPARENCY.— 

10 ‘‘(1) IN GENERAL.—For plan years beginning 

11 on or after the date that is 2 years after the date 

12 of the enactment of this section, a group health plan 

13 shall permit individuals to learn the amount of cost14 sharing (including deductibles, copayments, and co15 insurance) under the individual’s plan or coverage 

16 that the individual would be responsible for paying 

17 with respect to the furnishing of a specific item or 

18 service by a provider in a timely manner upon the 

19 request of the individual. At a minimum, such infor20 mation shall include the information specified in 

21 paragraph (2) and shall be made available to such 

22 individual through a self-service tool that meets the 

23 requirements of paragraph (3) or, at the option of 

24 such individual, through a paper disclosure or phone 

25 or other electronic disclosure (as selected by such in26 dividual and provided at no cost to such individual) 


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1 that meets such requirements as the Secretary may 

2 specify. 

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

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

5 paragraph is, with respect to an item or service for 

6 which benefits are available under a group health 

7 plan furnished by a health care provider to a partici8 pant or beneficiary of such plan, the following: 

9 ‘‘(A) If such provider is a participating 

10 provider with respect to such item or service, 

11 the in-network rate (as defined in subsection 

12 (c)) for such item or service. 

13 ‘‘(B) If such provider is not described in 

14 subparagraph (A), the maximum allowed 

15 amount for such item or service. 

16 ‘‘(C) The estimated amount of cost sharing 

17 (including deductibles, copayments, and coin18 surance) that the participant or beneficiary will 

19 incur for such item or service (which, in the 

20 case such item or service is to be furnished by 

21 a provider described in subparagraph (B), shall 

22 be calculated using the maximum amount de23 scribed in such subparagraph). 

24 ‘‘(D) The amount the participant or bene25 ficiary has already accumulated with respect to 


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1 any deductible or out of pocket maximum, 

2 whether for items and services furnished by a 

3 participating provider or for items and services 

4 furnished by a provider that is not a partici5 pating provider, under the plan (broken down, 

6 in the case separate deductibles or maximums 

7 apply to separate participants and beneficiaries 

8 enrolled in the plan, by such separate 

9 deductibles or maximums, in addition to any 

10 cumulative deductible or maximum). 

11 ‘‘(E) In the case such plan imposes any 

12 frequency or volume limitations with respect to 

13 such item or service (excluding medical neces14 sity determinations), the amount that such par15 ticipant or beneficiary has accrued towards such 

16 limitation with respect to such item or service. 

17 ‘‘(F) Any prior authorization, concurrent 

18 review, step therapy, fail first, or similar re19 quirements applicable to coverage of such item 

20 or service under such plan. 

21 The Secretary may provide that information de22 scribed in any of subparagraphs (A) through (F) not 

23 be treated as information specified in this para24 graph, and specify additional information that shall 


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1 be treated as information specified in this para2 graph, if determined appropriate by the Secretary. 

3 ‘‘(3) SELF-SERVICE TOOL.—For purposes of 

4 paragraph (1), a self-service tool established by a 

5 group health plan meets the requirements of this 

6 paragraph if such tool— 

7 ‘‘(A) is based on an Internet website; 

8 ‘‘(B) provides for real-time responses to re9 quests described in paragraph (1); 

10 ‘‘(C) is updated in a manner such that in11 formation provided through such tool is timely 

12 and accurate at the time such request is made; 

13 ‘‘(D) allows such a request to be made 

14 with respect to an item or service furnished 

15 by— 

16 ‘‘(i) a specific provider that is a par17 ticipating provider with respect to such 

18 item or service; 

19 ‘‘(ii) all providers that are partici20 pating providers with respect to such item 

21 or service; or 

22 ‘‘(iii) a provider that is not described 

23 in clause (ii); 

24 ‘‘(E) provides that such a request may be 

25 made with respect to an item or service through 


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1 use of the billing code for such item or service 

2 or through use of a descriptive term for such 

3 item or service; and 

4 ‘‘(F) meets any other requirement deter5 mined appropriate by the Secretary. 

6 The Secretary may require such tool, as a condition 

7 of complying with subparagraph (E), to link multiple 

8 billing codes to a single descriptive term if the Sec9 retary determines that the billing codes to be so 

10 linked correspond to similar items and services. 

11 ‘‘(b) RATE AND PAYMENT INFORMATION.— 

12 ‘‘(1) IN GENERAL.—For plan years beginning 

13 on or after the date that is 2 years after the date 

14 of the enactment of this section, each group health 

15 plan (other than a grandfathered health plan (as de16 fined in section 1251(e) of the Patient Protection 

17 and Affordable Care Act (42 U.S.C. 18011(e))) 

18 shall, not less frequently than once every 3 months 

19 (or, in the case of information described in para20 graph (2)(B), not less frequently than monthly), 

21 make available to the public the rate and payment 

22 information described in paragraph (2) in accord23 ance with paragraph (3). 

24 ‘‘(2) RATE AND PAYMENT INFORMATION DE25 SCRIBED.—For purposes of paragraph (1), the rate 


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1 and payment information described in this para2 graph is, with respect to a group health plan, the 

3 following: 

4 ‘‘(A) With respect to each item or service 

5 (other than a drug) for which benefits are avail6 able under such plan, the in-network rate in ef7 fect with each provider that is a participating 

8 provider with respect to such item or service, 

9 other than such a rate in effect with a provider 

10 that, during the 1-year period ending 10 busi11 ness days before the date of the publication of 

12 such information, did not submit any claim for 

13 such item or service to such plan. 

14 ‘‘(B) With respect to each drug (identified 

15 by national drug code) for which benefits are 

16 available under such plan, the average amount 

17 paid by such plan (net of rebates, discounts, 

18 and price concessions) for such drug dispensed 

19 or administered during the 90-day period begin20 ning 180 days before such date of publication 

21 to each provider that was a participating pro22 vider with respect to such drug, broken down by 

23 each such provider, other than such an amount 

24 paid to a provider that, during such period, 


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1 submitted fewer than 20 claims for such drug 

2 to such plan. 

3 ‘‘(C) With respect to each item or service 

4 for which benefits are available under such 

5 plan, the amount billed, and the amount al6 lowed by the plan, for each such item or service 

7 furnished during the 90-day period specified in 

8 subparagraph (B) by a provider that was not a 

9 participating provider with respect to such item 

10 or service, broken down by each such provider, 

11 other than items and services with respect to 

12 which fewer than 20 claims for such item or 

13 service were submitted to such plan during such 

14 period. 

15 ‘‘(3) MANNER OF PUBLICATION.—Rate and 

16 payment information required to be made available 

17 under this subsection shall be so made available in 

18 dollar amounts through 3 separate machine-readable 

19 files (or any successor technology, such as applica20 tion program interface technology, determined ap21 propriate by the Secretary) corresponding to the in22 formation described in each of subparagraphs (A) 

23 through (C) of paragraph (2) that meet such re24 quirements as specified by the Secretary. Such re25 quirements shall ensure that such files are limited to 


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1 an appropriate size, do not include disclosure of un2 necessary duplicative information contained in other 

3 files made available under this subsection, are made 

4 available in a widely-available format through a pub5 licly-available website that allows for information 

6 contained in such files to be compared across group 

7 health plans, and are accessible to individuals at no 

8 cost and without the need to establish a user ac9 count or provide other credentials. 

10 ‘‘(4) USER INSTRUCTIONS.—Each group health 

11 plan shall make available to the public instructions 

12 written in plain language explaining how individuals 

13 may search for information described in paragraph 

14 (2) in files submitted in accordance with paragraph 

15 (3). The Secretary shall develop and publish a tem16 plate that such a plan may use in developing in17 structions for purposes of the preceding sentence. 

18 ‘‘(5) ATTESTATION.—Each group health plan 

19 shall post, along with rate and payment information 

20 made public by such plan, an attestation that such 

21 information is complete and accurate. 

22 ‘‘(c) DEFINITIONS.—In this paragraph: 

23 ‘‘(1) PARTICIPATING PROVIDER.—The term 

24 ‘participating provider’ has the meaning given such 

25 term in section 9816. 


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1 ‘‘(2) IN-NETWORK RATE.—The term ‘in-net2 work rate’ means, with respect to a health plan and 

3 an item or service furnished by a provider that is a 

4 participating provider with respect to such plan and 

5 item or service, the contracted rate in effect between 

6 such plan and such provider for such item or serv7 ice.’’. 

8 (B) CLERICAL AMENDMENT.—The item re9 lating to section 9819 of the table of sections 

10 for subchapter B of chapter 100 of the Internal 

11 Revenue Code of 1986 is amended to read as 

12 follows: 

‘‘Sec. 9819. Price transparency requirements.’’. 

13 (2) PHSA.—Section 2799A–4 of the Public 

14 Health Service Act (42 U.S.C. 300gg–114) is 

15 amended to read as follows: 

16 ‘‘SEC. 2799A–4. PRICE TRANSPARENCY REQUIREMENTS. 

17 ‘‘(a) COST SHARING TRANSPARENCY.— 

18 ‘‘(1) IN GENERAL.—For plan years beginning 

19 on or after the date that is 2 years after the date 

20 of the enactment of this section, a group health plan 

21 or a health insurance issuer offering group or indi22 vidual health insurance coverage shall permit indi23 viduals to learn the amount of cost-sharing (includ24 ing deductibles, copayments, and coinsurance) under 

25 the individual’s plan or coverage that the individual 


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1 would be responsible for paying with respect to the 

2 furnishing of a specific item or service by a provider 

3 in a timely manner upon the request of the indi4 vidual. At a minimum, such information shall in5 clude the information specified in paragraph (2) and 

6 shall be made available to such individual through a 

7 self-service tool that meets the requirements of para8 graph (3) or, at the option of such individual, 

9 through a paper disclosure or phone or other elec10 tronic disclosure (as selected by such individual and 

11 provided at no cost to such individual) that meets 

12 such requirements as the Secretary may specify. 

13 ‘‘(2) SPECIFIED INFORMATION.—For purposes 

14 of paragraph (1), the information specified in this 

15 paragraph is, with respect to an item or service for 

16 which benefits are available under a group health 

17 plan or group or individual health insurance cov18 erage furnished by a health care provider to a par19 ticipant or beneficiary of such plan, or enrollee in 

20 such coverage, the following: 

21 ‘‘(A) If such provider is a participating 

22 provider with respect to such item or service, 

23 the in-network rate (as defined in subsection 

24 (c)) for such item or service. 


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1 ‘‘(B) If such provider is not described in 

2 subparagraph (A), the maximum allowed 

3 amount for such item or service. 

4 ‘‘(C) The estimated amount of cost sharing 

5 (including deductibles, copayments, and coin6 surance) that the participant or beneficiary will 

7 incur for such item or service (which, in the 

8 case such item or service is to be furnished by 

9 a provider described in subparagraph (B), shall 

10 be calculated using the maximum amount de11 scribed in such subparagraph). 

12 ‘‘(D) The amount the participant, bene13 ficiary, or enrollee has already accumulated 

14 with respect to any deductible or out of pocket 

15 maximum, whether for items and services fur16 nished by a participating provider or for items 

17 and services furnished by a provider that is not 

18 a participating provider, under the plan or cov19 erage (broken down, in the case separate 

20 deductibles or maximums apply to separate par21 ticipants, beneficiaries or enrollees enrolled in 

22 the plan or coverage, by such separate 

23 deductibles or maximums, in addition to any 

24 cumulative deductible or maximum). 


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1 ‘‘(E) In the case such plan or coverage im2 poses any frequency or volume limitations with 

3 respect to such item or service (excluding med4 ical necessity determinations), the amount that 

5 such participant, beneficiary, or enrollee has ac6 crued towards such limitation with respect to 

7 such item or service. 

8 ‘‘(F) Any prior authorization, concurrent 

9 review, step therapy, fail first, or similar re10 quirements applicable to coverage of such item 

11 or service under such plan or coverage. 

12 The Secretary may provide that information de13 scribed in any of subparagraphs (A) through (F) not 

14 be treated as information specified in this para15 graph, and specify additional information that shall 

16 be treated as information specified in this para17 graph, if determined appropriate by the Secretary. 

18 ‘‘(3) SELF-SERVICE TOOL.—For purposes of 

19 paragraph (1), a self-service tool established by a 

20 group health plan or group or individual health in21 surance coverage meets the requirements of this 

22 paragraph if such tool— 

23 ‘‘(A) is based on an Internet website; 

24 ‘‘(B) provides for real-time responses to re25 quests described in paragraph (1); 


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1 ‘‘(C) is updated in a manner such that in2 formation provided through such tool is timely 

3 and accurate at the time such request is made; 

4 ‘‘(D) allows such a request to be made 

5 with respect to an item or service furnished 

6 by— 

7 ‘‘(i) a specific provider that is a par8 ticipating provider with respect to such 

9 item or service; 

10 ‘‘(ii) all providers that are partici11 pating providers with respect to such item 

12 or service; or 

13 ‘‘(iii) a provider that is not described 

14 in clause (ii); 

15 ‘‘(E) provides that such a request may be 

16 made with respect to an item or service through 

17 use of the billing code for such item or service 

18 or through use of a descriptive term for such 

19 item or service; and 

20 ‘‘(F) meets any other requirement deter21 mined appropriate by the Secretary. 

22 The Secretary may require such tool, as a condition 

23 of complying with subparagraph (E), to link multiple 

24 billing codes to a single descriptive term if the SecVerDate Sep 11 2014 04:08 Aug 11, 2023 Jkt 039200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 E:\BILLS\H4905.IH H4905

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1 retary determines that the billing codes to be so 

2 linked correspond to similar items and services. 

3 ‘‘(b) RATE AND PAYMENT INFORMATION.— 

4 ‘‘(1) IN GENERAL.—For plan years beginning 

5 on or after the date that is 2 years after the date 

6 of the enactment of this section, each group health 

7 plan (other than a grandfathered health plan (as de8 fined in section 1251(e) of the Patient Protection 

9 and Affordable Care Act (42 U.S.C. 18011(e))) or 

10 group or individual health insurance coverage, shall, 

11 not less frequently than once every 3 months (or, in 

12 the case of information described in paragraph 

13 (2)(B), not less frequently than monthly), make 

14 available to the public the rate and payment infor15 mation described in paragraph (2) in accordance 

16 with paragraph (3). 

17 ‘‘(2) RATE AND PAYMENT INFORMATION DE18 SCRIBED.—For purposes of paragraph (1), the rate 

19 and payment information described in this para20 graph is, with respect to a group health plan or 

21 group or individual health insurance coverage, the 

22 following: 

23 ‘‘(A) With respect to each item or service 

24 (other than a drug) for which benefits are avail25 able under such plan or coverage, the in-netVerDate Sep 11 2014 04:08 Aug 11, 2023 Jkt 039200 PO 00000 Frm 00015 Fmt 6652 Sfmt 6201 E:\BILLS\H4905.IH H4905

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1 work rate in effect with each provider that is a 

2 participating provider with respect to such item 

3 or service, other than such a rate in effect with 

4 a provider that, during the 1-year period ending 

5 10 business days before the date of the publica6 tion of such information, did not submit any 

7 claim for such item or service to such plan or 

8 coverage. 

9 ‘‘(B) With respect to each drug (identified 

10 by national drug code) for which benefits are 

11 available under such plan, the average amount 

12 paid by such plan or coverage (net of rebates, 

13 discounts, and price concessions) for such drug 

14 dispensed or administered during the 90-day 

15 period beginning 180 days before such date of 

16 publication to each provider that was a partici17 pating provider with respect to such drug, bro18 ken down by each such provider, other than 

19 such an amount paid to a provider that, during 

20 such period, submitted fewer than 20 claims for 

21 such drug to such plan or coverage. 

22 ‘‘(C) With respect to each item or service 

23 for which benefits are available under such plan 

24 or coverage, the amount billed, and the amount 

25 allowed by the plan or coverage, for each such 


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1 item or service furnished during the 90-day pe2 riod specified in subparagraph (B) by a pro3 vider that was not a participating provider with 

4 respect to such item or service, broken down by 

5 each such provider, other than items and serv6 ices with respect to which fewer than 20 claims 

7 for such item or service were submitted to such 

8 plan or coverage during such period. 

9 ‘‘(3) MANNER OF PUBLICATION.—Rate and 

10 payment information required to be made available 

11 under this subsection shall be so made available in 

12 dollar amounts through 3 separate machine-readable 

13 files (or any successor technology, such as applica14 tion program interface technology, determined ap15 propriate by the Secretary) corresponding to the in16 formation described in each of subparagraphs (A) 

17 through (C) of paragraph (2) that meet such re18 quirements as specified by the Secretary. Such re19 quirements shall ensure that such files are limited to 

20 an appropriate size, do not include disclosure of un21 necessary duplicative information contained in other 

22 files made available under this subsection, are made 

23 available in a widely-available format through a pub24 licly-available website that allows for information 

25 contained in such files to be compared across group 


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1 health plans and group and individual health insur2 ance coverage, and are accessible to individuals at no 

3 cost and without the need to establish a user ac4 count or provide other credentials. 

5 ‘‘(4) USER INSTRUCTIONS.—Each group health 

6 plan and group or individual health insurance cov7 erage shall make available to the public instructions 

8 written in plain language explaining how individuals 

9 may search for information described in paragraph 

10 (2) in files submitted in accordance with paragraph 

11 (3). The Secretary shall develop and publish a tem12 plate that such a plan or coverage may use in devel13 oping instructions for purposes of the preceding sen14 tence. 

15 ‘‘(5) ATTESTATION.—Each group health plan 

16 and group or individual health insurance coverage 

17 shall post, along with rate and payment information 

18 made public by such plan or coverage, an attestation 

19 that such information is complete and accurate. 

20 ‘‘(c) DEFINITIONS.—In this paragraph: 

21 ‘‘(1) PARTICIPATING PROVIDER.—The term 

22 ‘participating provider’ has the meaning given such 

23 term in section 2791A–1(a)(3)(G)(ii). 

24 ‘‘(2) IN-NETWORK RATE.—The term ‘in-net25 work rate’ means, with respect to a health plan or 


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1 coverage and an item or service furnished by a pro2 vider that is a participating provider with respect to 

3 such plan and item or service, the contracted rate in 

4 effect between such plan or coverage and such pro5 vider for such item or service.’’. 

6 (3) ERISA.— 

7 (A) IN GENERAL.—Section 719 of the Em8 ployee Retirement Income Security Act of 1974 

9 (29 U.S.C. 1185h) is amended to read as fol10 lows: 

11 ‘‘SEC. 719. PRICE TRANSPARENCY REQUIREMENTS. 

12 ‘‘(a) COST SHARING TRANSPARENCY.— 

13 ‘‘(1) IN GENERAL.—For plan years beginning 

14 on or after the date that is 2 years after the date 

15 of the enactment of this section, a group health plan 

16 or a health insurance issuer offering group health 

17 insurance coverage shall permit individuals to learn 

18 the amount of cost-sharing (including deductibles, 

19 copayments, and coinsurance) under the individual’s 

20 plan or coverage that the individual would be re21 sponsible for paying with respect to the furnishing 

22 of a specific item or service by a provider in a timely 

23 manner upon the request of the individual. At a 

24 minimum, such information shall include the infor25 mation specified in paragraph (2) and shall be made 


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1 available to such individual through a self-service 

2 tool that meets the requirements of paragraph (3) 

3 or, at the option of such individual, through a paper 

4 disclosure or phone or other electronic disclosure (as 

5 selected by such individual and provided at no cost 

6 to such individual) that meets such requirements as 

7 the Secretary may specify. 

8 ‘‘(2) SPECIFIED INFORMATION.—For purposes 

9 of paragraph (1), the information specified in this 

10 paragraph is, with respect to an item or service for 

11 which benefits are available under a group health 

12 plan or group health insurance coverage furnished 

13 by a health care provider to a participant or bene14 ficiary of such plan, or enrollee in such coverage, the 

15 following: 

16 ‘‘(A) If such provider is a participating 

17 provider with respect to such item or service, 

18 the in-network rate (as defined in subsection 

19 (c)) for such item or service. 

20 ‘‘(B) If such provider is not described in 

21 subparagraph (A), the maximum allowed 

22 amount for such item or service. 

23 ‘‘(C) The estimated amount of cost sharing 

24 (including deductibles, copayments, and coin25 surance) that the participant or beneficiary will 


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1 incur for such item or service (which, in the 

2 case such item or service is to be furnished by 

3 a provider described in subparagraph (B), shall 

4 be calculated using the maximum amount de5 scribed in such subparagraph). 

6 ‘‘(D) The amount the participant, bene7 ficiary, or enrollee has already accumulated 

8 with respect to any deductible or out of pocket 

9 maximum, whether for items and services fur10 nished by a participating provider or for items 

11 and services furnished by a provider that is not 

12 a participating provider, under the plan or cov13 erage (broken down, in the case separate 

14 deductibles or maximums apply to separate par15 ticipants, beneficiaries or enrollees enrolled in 

16 the plan or coverage, by such separate 

17 deductibles or maximums, in addition to any 

18 cumulative deductible or maximum). 

19 ‘‘(E) In the case such plan or coverage im20 poses any frequency or volume limitations with 

21 respect to such item or service (excluding med22 ical necessity determinations), the amount that 

23 such participant, beneficiary, or enrollee has ac24 crued towards such limitation with respect to 

25 such item or service. 


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1 ‘‘(F) Any prior authorization, concurrent 

2 review, step therapy, fail first, or similar re3 quirements applicable to coverage of such item 

4 or service under such plan or coverage. 

5 The Secretary may provide that information de6 scribed in any of subparagraphs (A) through (F) not 

7 be treated as information specified in this para8 graph, and specify additional information that shall 

9 be treated as information specified in this para10 graph, if determined appropriate by the Secretary. 

11 ‘‘(3) SELF-SERVICE TOOL.—For purposes of 

12 paragraph (1), a self-service tool established by a 

13 group health plan or group health insurance cov14 erage meets the requirements of this paragraph if 

15 such tool— 

16 ‘‘(A) is based on an Internet website; 

17 ‘‘(B) provides for real-time responses to re18 quests described in paragraph (1); 

19 ‘‘(C) is updated in a manner such that in20 formation provided through such tool is timely 

21 and accurate at the time such request is made; 

22 ‘‘(D) allows such a request to be made 

23 with respect to an item or service furnished 

24 by— 


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1 ‘‘(i) a specific provider that is a par2 ticipating provider with respect to such 

3 item or service; 

4 ‘‘(ii) all providers that are partici5 pating providers with respect to such item 

6 or service; or 

7 ‘‘(iii) a provider that is not described 

8 in clause (ii); 

9 ‘‘(E) provides that such a request may be 

10 made with respect to an item or service through 

11 use of the billing code for such item or service 

12 or through use of a descriptive term for such 

13 item or service; and 

14 ‘‘(F) meets any other requirement deter15 mined appropriate by the Secretary. 

16 The Secretary may require such tool, as a condition 

17 of complying with subparagraph (E), to link multiple 

18 billing codes to a single descriptive term if the Sec19 retary determines that the billing codes to be so 

20 linked correspond to similar items and services. 

21 ‘‘(b) RATE AND PAYMENT INFORMATION.— 

22 ‘‘(1) IN GENERAL.—For plan years beginning 

23 on or after the date that is 2 years after the date 

24 of the enactment of this section, each group health 

25 plan (other than a grandfathered health plan (as deVerDate Sep 11 2014 04:08 Aug 11, 2023 Jkt 039200 PO 00000 Frm 00023 Fmt 6652 Sfmt 6201 E:\BILLS\H4905.IH H4905

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1 fined in section 1251(e) of the Patient Protection 

2 and Affordable Care Act (42 U.S.C. 18011(e))) or 

3 group health insurance coverage, shall, not less fre4 quently than once every 3 months (or, in the case 

5 of information described in paragraph (2)(B), not 

6 less frequently than monthly), make available to the 

7 public the rate and payment information described 

8 in paragraph (2) in accordance with paragraph (3). 

9 ‘‘(2) RATE AND PAYMENT INFORMATION DE10 SCRIBED.—For purposes of paragraph (1), the rate 

11 and payment information described in this para12 graph is, with respect to a group health plan or 

13 group health insurance coverage, the following: 

14 ‘‘(A) With respect to each item or service 

15 (other than a drug) for which benefits are avail16 able under such plan or coverage, the in-net17 work rate in effect with each provider that is a 

18 participating provider with respect to such item 

19 or service, other than such a rate in effect with 

20 a provider that, during the 1-year period ending 

21 10 business days before the date of the publica22 tion of such information, did not submit any 

23 claim for such item or service to such plan or 

24 coverage. 


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1 ‘‘(B) With respect to each drug (identified 

2 by national drug code) for which benefits are 

3 available under such plan, the average amount 

4 paid by such plan or coverage (net of rebates, 

5 discounts, and price concessions) for such drug 

6 dispensed or administered during the 90-day 

7 period beginning 180 days before such date of 

8 publication to each provider that was a partici9 pating provider with respect to such drug, bro10 ken down by each such provider, other than 

11 such an amount paid to a provider that, during 

12 such period, submitted fewer than 20 claims for 

13 such drug to such plan or coverage. 

14 ‘‘(C) With respect to each item or service 

15 for which benefits are available under such plan 

16 or coverage, the amount billed, and the amount 

17 allowed by the plan or coverage, for each such 

18 item or service furnished during the 90-day pe19 riod specified in subparagraph (B) by a pro20 vider that was not a participating provider with 

21 respect to such item or service, broken down by 

22 each such provider, other than items and serv23 ices with respect to which fewer than 20 claims 

24 for such item or service were submitted to such 

25 plan or coverage during such period. 


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1 ‘‘(3) MANNER OF PUBLICATION.—Rate and 

2 payment information required to be made available 

3 under this subsection shall be so made available in 

4 dollar amounts through 3 separate machine-readable 

5 files (or any successor technology, such as applica6 tion program interface technology, determined ap7 propriate by the Secretary) corresponding to the in8 formation described in each of subparagraphs (A) 

9 through (C) of paragraph (2) that meet such re10 quirements as specified by the Secretary. Such re11 quirements shall ensure that such files are limited to 

12 an appropriate size, do not include disclosure of un13 necessary duplicative information contained in other 

14 files made available under this subsection, are made 

15 available in a widely-available format through a pub16 licly-available website that allows for information 

17 contained in such files to be compared across group 

18 health plans and group and individual health insur19 ance coverage, and are accessible to individuals at no 

20 cost and without the need to establish a user ac21 count or provide other credentials. 

22 ‘‘(4) USER INSTRUCTIONS.—Each group health 

23 plan and group health insurance coverage shall make 

24 available to the public instructions written in plain 

25 language explaining how individuals may search for 


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1 information described in paragraph (2) in files sub2 mitted in accordance with paragraph (3). The Sec3 retary shall develop and publish a template that 

4 such a plan or coverage may use in developing in5 structions for purposes of the preceding sentence. 

6 ‘‘(5) ATTESTATION.—Each group health plan 

7 and group health insurance coverage shall post, 

8 along with rate and payment information made pub9 lic by such plan or coverage, an attestation that such 

10 information is complete and accurate. 

11 ‘‘(c) DEFINITIONS.—In this paragraph: 

12 ‘‘(1) PARTICIPATING PROVIDER.—The term 

13 ‘participating provider’ has the meaning given such 

14 term in section 2791A–1(a)(3)(G)(ii). 

15 ‘‘(2) IN-NETWORK RATE.—The term ‘in-net16 work rate’ means, with respect to a health plan or 

17 coverage and an item or service furnished by a pro18 vider that is a participating provider with respect to 

19 such plan and item or service, the contracted rate in 

20 effect between such plan or coverage and such pro21 vider for such item or service.’’. 

22 (B) CLERICAL AMENDMENT.—The table of 

23 contents in section 1 of the Employee Retire24 ment Income Security Act of 1974 is amended 


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1 by striking the item relating to section 719 and 

2 inserting the following new item: 

‘‘Sec. 719. Price transparency requirements.’’. 

3 (b) ACCESSIBILITY THROUGH IMPLEMENTATION.— 

4 In implementing the amendments made by subsection (a), 

5 the Secretary of the Treasury, the Secretary of Health and 

6 Human Services, and the Secretary of Labor shall take 

7 reasonable steps to ensure the accessibility of information 

8 made available pursuant to such amendments, including 

9 reasonable steps to ensure that such information is pro10 vided in plain, easily understandable language and that 

11 interpretation, translations, and assistive services are pro12 vided by group health plans and health insurance issuers 

13 offering group or individual health insurance coverage to 

14 make such information accessible to those with limited 

15 English proficiency and those with disabilities. 

16 (c) CONTINUED APPLICABILITY OF RULES FOR PRE17 VIOUS YEARS.—Nothing in the amendments made by sub18 section (a) may be construed as affecting the applicability 

19 of the rule entitled ‘‘Transparency in Coverage’’ published 

20 by the Department of the Treasury, the Department of 

21 Labor, and the Department of Health and Human Serv22 ices on November 12, 2020 (85 Fed. Reg. 72158) for any 

23 plan year beginning before the date that is 2 years after 

24 the date of the enactment of this Act. 

Æ 


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