I 

118TH CONGRESS 

1ST SESSION H. R. 5378 

To promote price transparency in the health care sector, and for other 

purposes. 

IN THE HOUSE OF REPRESENTATIVES 

SEPTEMBER 8, 2023 

Mrs. RODGERS of Washington (for herself, Mr. PALLONE, Mr. SMITH of Missouri, and Ms. FOXX) 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 Education and the Workforce, 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 promote price transparency in the health care sector, 

and for other purposes. 

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 ‘‘Lower Costs, More 

5 Transparency Act’’. 

6 SEC. 2. TABLE OF CONTENTS. 

7 The table of contents of this Act is as follows: 

Sec. 1. Short title. 

Sec. 2. Table of contents. 


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TITLE I—IMPROVING HEALTH CARE TRANSPARENCY 

Sec. 101. Hospital price transparency. 

Sec. 102. Clinical diagnostic laboratory test price transparency. 

Sec. 103. Imaging price transparency. 

Sec. 104. Ambulatory surgical center price transparency. 

Sec. 105. Health coverage price transparency. 

Sec. 106. Pharmacy benefits price transparency. 

Sec. 107. Reports on health care transparency tools and data. 

Sec. 108. Report on integration in Medicare. 

Sec. 109. Advisory Committee. 

Sec. 110. Report on impact of Medicare regulations on provider and payer consolidation. 

Sec. 111. Implementation funding. 

TITLE II—REDUCING HEALTH CARE COSTS FOR PATIENTS 

Sec. 201. Increasing transparency in generic drug applications. 

Sec. 202. Improving transparency and preventing the use of abusive spread 

pricing and related practices in Medicaid. 

Sec. 203. Parity in Medicare payments for hospital outpatient department services furnished off-campus. 

Sec. 204. Requiring a separate identification number and an attestation for 

each off-campus outpatient department of a provider. 

TITLE III—SUPPORTING PATIENTS, HEALTH CARE WORKERS, 

COMMUNITY HEALTH CENTERS, AND HOSPITALS 

Sec. 301. Extension for community health centers, the national health service 

corps, and teaching health centers that operate GME programs. 

Sec. 302. Extension of special diabetes programs. 

Sec. 303. Delaying certain disproportionate share hospital payment reductions 

under the Medicaid program. 

Sec. 304. Medicaid improvement fund. 

TITLE IV—INCREASING ACCESS TO QUALITY HEALTH DATA AND 

LOWERING HIDDEN FEES 

Sec. 401. Increasing Plan Fiduciaries’ Access to Health Data. 

Sec. 402. Hidden Fees Disclosure Requirements. 

Sec. 403. Prescription drug price information requirement. 

Sec. 404. Implementation funding. 

1 TITLE I—IMPROVING HEALTH 

2 CARE TRANSPARENCY 

3 SEC. 101. HOSPITAL PRICE TRANSPARENCY. 

4 (a) MEDICARE.—Part E of title XVIII of the Social 

5 Security Act (42 U.S.C. 1395x et seq.) is amended by add6 ing at the end the following new section: 


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1 ‘‘SEC. 1899C. HOSPITAL PRICE TRANSPARENCY. 

2 ‘‘(a) TRANSPARENCY REQUIREMENT.— 

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

4 2026, each specified hospital that receives payment 

5 under this title for furnishing items and services 

6 shall comply with the price transparency require7 ment described in paragraph (2). 

8 ‘‘(2) REQUIREMENT DESCRIBED.— 

9 ‘‘(A) IN GENERAL.—For purposes of para10 graph (1), the price transparency requirement 

11 described in this paragraph is, with respect to 

12 a specified hospital, that such hospital, in ac13 cordance with a method and format established 

14 by the Secretary under subparagraph (C), com15 pile and make public (without subscription and 

16 free of charge) for each year— 

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; 

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; and 

11 ‘‘(II) that includes, with respect 

12 to each Centers for Medicare & Med13 icaid Services-specified shoppable 

14 service that is not furnished by the 

15 hospital, an indication that such serv16 ice is not so furnished; and 

17 ‘‘(iii) an attestation that all informa18 tion made public pursuant to this subpara19 graph is complete and accurate. 

20 ‘‘(B) INFORMATION DESCRIBED.—For pur21 poses of subparagraph (A), the information de22 scribed in this subparagraph is, with respect to 

23 standard charges and prices, as applicable, 

24 made public by a specified hospital, the fol25 lowing: 


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1 ‘‘(i) A plain language description of 

2 each item or service, accompanied by, as 

3 applicable, the Healthcare Common Proce4 dure Coding System code, the diagnosis-re5 lated group, the national drug code, or 

6 other identifier used or approved by the 

7 Centers for Medicare & Medicaid Services. 

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

9 expressed as a dollar amount, for each 

10 such item or service, when provided in, as 

11 applicable, the inpatient setting and out12 patient department setting. 

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

14 applicable, expressed as a dollar amount, 

15 for each such item or service when pro16 vided in, as applicable, the inpatient set17 ting and outpatient department setting (or, 

18 in the case no discounted cash price is 

19 available for an item or service, the median 

20 cash price charged by the hospital to self21 pay individuals for such item or service 

22 when provided in such settings for the pre23 vious three years, expressed as a dollar 

24 amount, as well as, with respect to prices 

25 made public pursuant to subparagraph 


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1 (A)(ii), a link to a consumer-friendly docu2 ment that clearly explains the hospital’s 

3 charity care policy that includes, if applica4 ble, any sliding scale payment structure 

5 employed for determining charges for a 

6 self-pay individual). 

7 ‘‘(iv) The payer-specific negotiated 

8 charges, as applicable, clearly associated 

9 with the name of the third party payer and 

10 plan and expressed as a dollar amount, 

11 that apply to each such item or service 

12 when provided in, as applicable, the inpa13 tient setting and outpatient department 

14 setting. 

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

16 minimum negotiated charges, as applica17 ble, for each such item or service. 

18 ‘‘(vi) Any other additional information 

19 the Secretary may require for the purpose 

20 of improving the accuracy of, or enabling 

21 consumers to easily understand and com22 pare, standard charges and prices for an 

23 item or service, except information that is 

24 duplicative of any other reporting require25 ment under this subsection. 


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1 In the case of standard charges and prices for 

2 an item or service included as part of a bun3 dled, per diem, episodic, or other similar ar4 rangement, the information described in this 

5 subparagraph shall be made available as deter6 mined appropriate by the Secretary. 

7 ‘‘(C) UNIFORM METHOD AND FORMAT.— 

8 Not later than January 1, 2026, the Secretary 

9 shall establish a standard, uniform method and 

10 format for specified hospitals to use in com11 piling and making public standard charges pur12 suant to subparagraph (A)(i) and a standard, 

13 uniform method and format for such hospitals 

14 to use in compiling and making public prices 

15 pursuant to subparagraph (A)(ii). Such meth16 ods and formats— 

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

18 and format for making public standard 

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

20 ensure that such charges are made avail21 able in a machine-readable format (or a 

22 successor technology specified by the Sec23 retary); 

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

25 made available by the Centers for Medicare 


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1 & Medicaid Services as of the date of the 

2 enactment of this subparagraph; 

3 ‘‘(iii) shall meet such standards as de4 termined appropriate by the Secretary in 

5 order to ensure the accessibility and 

6 usability of such charges and prices; and 

7 ‘‘(iv) shall be updated as determined 

8 appropriate by the Secretary, in consulta9 tion with stakeholders. 

10 ‘‘(3) MONITORING COMPLIANCE.—The Sec11 retary shall, through notice and comment rule12 making and in consultation with the Inspector Gen13 eral of the Department of Health and Human Serv14 ices, establish a process to monitor compliance with 

15 this subsection. Such process shall ensure that each 

16 specified hospital’s compliance with this subsection 

17 is reviewed not less frequently than once every 3 

18 years. 

19 ‘‘(4) ENFORCEMENT.— 

20 ‘‘(A) IN GENERAL.—In the case of a speci21 fied hospital that fails to comply with the re22 quirements of this subsection— 

23 ‘‘(i) not later than 30 days after the 

24 date on which the Secretary determines 

25 such failure exists, the Secretary shall subVerDate Sep 11 2014 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 mit to such hospital a notification of such 

2 determination (which may include, as de3 termined appropriate by the Secretary, a 

4 request for a corrective action plan to com5 ply with such requirements); and 

6 ‘‘(ii) in the case of a hospital that 

7 does not receive a request for a corrective 

8 action plan as part of a notification sub9 mitted by the Secretary under clause (i)— 

10 ‘‘(I) the Secretary shall, not later 

11 than 45 days after such notification is 

12 sent, determine whether such hospital 

13 is in compliance with such require14 ments; and 

15 ‘‘(II) if the Secretary determines 

16 under subclause (I) that such hospital 

17 is not in compliance with such re18 quirements, the Secretary shall ei19 ther— 

20 ‘‘(aa) submit to such hos21 pital a request for a corrective 

22 action plan to comply with such 

23 requirements; or 

24 ‘‘(bb) if the Secretary deter25 mines that such hospital has not 


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1 taken meaningful actions to come 

2 into compliance since such notifi3 cation was sent, impose a civil 

4 monetary penalty in accordance 

5 with subparagraph (B). 

6 ‘‘(B) CIVIL MONETARY PENALTY.— 

7 ‘‘(i) IN GENERAL.—Subject to clause 

8 (vii), in addition to any other enforcement 

9 actions or penalties that may apply under 

10 another provision of law, a specified hos11 pital that has received a request for a cor12 rective action plan under clause (i) or (ii) 

13 of subparagraph (A) and fails to comply 

14 with the requirements of this subsection by 

15 the date that is 45 days after such request 

16 is made, and a specified hospital with re17 spect to which the Secretary has made a 

18 determination described in clause 

19 (ii)(II)(bb) of such subparagraph, shall be 

20 subject to a civil monetary penalty of an 

21 amount specified by the Secretary for each 

22 day (beginning with the day on which the 

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1 ments) during which such failure was on2 going. Such amount shall not exceed— 

3 ‘‘(I) in the case of a specified 

4 hospital with 30 or fewer beds, $300 

5 per day (or, in the case of such a hos6 pital that has been noncompliant with 

7 such requirements for a 1-year period 

8 or longer, beginning with the first day 

9 following such 1-year period, $400 per 

10 day); 

11 ‘‘(II) in the case of a specified 

12 hospital with more than 30 beds but 

13 fewer than 101 beds, $12.50 per bed 

14 per day (or, in the case of such a hos15 pital that has been noncompliant with 

16 such requirements for a 1-year period 

17 or longer, beginning with the first day 

18 following such 1-year period, $15 per 

19 bed per day); 

20 ‘‘(III) in the case of a specified 

21 hospital with more than 100 beds but 

22 fewer than 201 beds, $17.50 per bed 

23 per day (or, in the case of such a hos24 pital that has been noncompliant with 

25 such requirements for a 1-year period 


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1 or longer, beginning with the first day 

2 following such 1-year period, $20 per 

3 bed per day); 

4 ‘‘(IV) in the case of a specified 

5 hospital with more than 200 beds but 

6 fewer than 501 beds, $20 per bed per 

7 day (or, in the case of such a hospital 

8 that has been noncompliant with such 

9 requirements for a 1-year period or 

10 longer, beginning with the first day 

11 following such 1-year period, $25 per 

12 bed per day); and 

13 ‘‘(V) in the case of a specified 

14 hospital with more than 500 beds, 

15 $25 per bed per day (or, in the case 

16 of such a hospital that has been non17 compliant with such requirements for 

18 a 1-year period or longer, beginning 

19 with the first day following such 1- 

20 year period, $35 per bed per day). 

21 ‘‘(ii) INCREASE AUTHORITY.—In ap22 plying this subparagraph with respect to 

23 violations occurring in 2027 or a subse24 quent year, the Secretary may through no25 tice and comment rulemaking increase— 


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

2 amount of any penalty applicable to a 

3 specified hospital under clause (i)(I); 

4 ‘‘(II) the limitations on the per 

5 bed per day amount of any penalty 

6 applicable under any of subclauses 

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

8 ‘‘(III) the amounts specified in 

9 clause (iii)(II). 

10 ‘‘(iii) PERSISTENT NONCOMPLI11 ANCE.— 

12 ‘‘(I) IN GENERAL.—In the case 

13 of a specified hospital (other than a 

14 specified hospital with 30 or fewer 

15 beds) that the Secretary has deter16 mined to be knowingly and willfully 

17 noncompliant with the provisions of 

18 this subsection two or more times dur19 ing a 1-year period, the Secretary may 

20 increase any penalty otherwise appli21 cable under this subparagraph by the 

22 amount specified in subclause (II) 

23 with respect to such hospital and may 

24 require such hospital to complete such 


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1 additional corrective actions plans as 

2 the Secretary may specify. 

3 ‘‘(II) SPECIFIED AMOUNT.—For 

4 purposes of subclause (I), the amount 

5 specified in this subclause is, with re6 spect to a specified hospital— 

7 ‘‘(aa) with more than 30 

8 beds but fewer than 101 beds, an 

9 amount that is not less than 

10 $500,000 and not more than 

11 $1,000,000; 

12 ‘‘(bb) with more than 100 

13 beds but fewer than 301 beds, an 

14 amount that is greater than 

15 $1,000,000 and not more than 

16 $2,000,000; 

17 ‘‘(cc) with more than 300 

18 beds but fewer than 501 beds, an 

19 amount that is greater than 

20 $2,000,000 and not more than 

21 $4,000,000; and 

22 ‘‘(dd) with more than 500 

23 beds, and amount that is not less 

24 than $5,000,000 and not more 

25 than $10,000,000. 


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1 ‘‘(iv) AUTHORITY TO WAIVE OR RE2 DUCE PENALTY.— 

3 ‘‘(I) IN GENERAL.—Subject to 

4 subclause (II), the Secretary may 

5 waive any penalty, or reduce any pen6 alty by not more than 75 percent, oth7 erwise applicable under this subpara8 graph with respect to a specified hos9 pital located in a rural or underserved 

10 area if the Secretary certifies that im11 position of such penalty would result 

12 in an immediate threat to access to 

13 care for individuals in the service area 

14 of such hospital. 

15 ‘‘(II) LIMITATION ON APPLICA16 TION.—The Secretary may not elect 

17 to waive a penalty under subclause (I) 

18 with respect to a specified hospital 

19 more than once in a 6-year period and 

20 may not elect to reduce such a penalty 

21 with respect to such a hospital more 

22 than once in such a period. Nothing 

23 in the preceding sentence shall be con24 strued as prohibiting the Secretary 

25 from both waiving and reducing a 


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1 penalty with respect to a specified 

2 hospital during a 6-year period. 

3 ‘‘(v) PROVISION OF TECHNICAL AS4 SISTANCE.—The Secretary shall, to the ex5 tent practicable, provide technical assist6 ance relating to compliance with the provi7 sions of this subsection to specified hos8 pitals requesting such assistance. 

9 ‘‘(vi) APPLICATION OF CERTAIN PRO10 VISIONS.—The provisions of section 1128A 

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

12 section) shall apply to a civil monetary 

13 penalty imposed under this subparagraph 

14 in the same manner as such provisions 

15 apply to a civil monetary penalty imposed 

16 under subsection (a) of such section. 

17 ‘‘(vii) NONDUPLICATION OF CERTAIN

18 PENALTIES.—The Secretary may not sub19 ject a specified hospital to a civil monetary 

20 penalty under this subparagraph with re21 spect to noncompliance with the provisions 

22 of this section for a period if the Secretary 

23 has imposed a civil monetary penalty on 

24 such hospital under section 2718(f) of the 

25 Public Health Service Act for failure to 


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1 comply with the provisions of such section 

2 for such period. 

3 ‘‘(C) PUBLICATION OF HOSPITAL PRICE

4 TRANSPARENCY INFORMATION.—Beginning on 

5 January 1, 2026, the Secretary shall make pub6 licly available on the public website of the Cen7 ters for Medicare & Medicaid Services informa8 tion with respect to compliance with the re9 quirements of this subsection and enforcement 

10 activities undertaken by the Secretary under 

11 this subsection. Such information shall be up12 dated in real time and include— 

13 ‘‘(i) the number of reviews of compli14 ance with this subsection undertaken by 

15 the Secretary; 

16 ‘‘(ii) the number of notifications de17 scribed in subparagraph (A)(i) sent by the 

18 Secretary; 

19 ‘‘(iii) the identity of each specified 

20 hospital that was sent such a notification 

21 and a description of the nature of such 

22 hospital’s noncompliance with this sub23 section; 


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1 ‘‘(iv) the amount of any civil monetary 

2 penalty imposed on such hospital under 

3 subparagraph (B); 

4 ‘‘(v) whether such hospital subse5 quently came into compliance with this 

6 subsection; 

7 ‘‘(vi) any waivers or reductions of 

8 penalties made pursuant to a certification 

9 by the Secretary under subparagraph 

10 (B)(iv), including— 

11 ‘‘(I) the name of any specified 

12 hospital that received such a waiver or 

13 reduction; 

14 ‘‘(II) the dollar amount of each 

15 such penalty so waived or reduced; 

16 and 

17 ‘‘(III) the rationale for the grant18 ing of each such waiver or reduction; 

19 and 

20 ‘‘(vii) any other information as deter21 mined by the Secretary. 

22 ‘‘(b) ENSURING ACCESSIBILITY THROUGH IMPLE23 MENTATION.—In implementing the amendments made by 

24 this section, the Secretary of Health and Human Services 

25 shall through rulemaking ensure that a hospital submitVerDate Sep 11 2014 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00018 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 ting charges and information pursuant to such amend2 ments takes reasonable steps (as specified by the Sec3 retary) to ensure the accessibility of such charges and in4 formation to individuals with limited English proficiency. 

5 Such steps may include the hospital’s provision of inter6 pretation services or the hospital’s provision of trans7 lations of charges and information. 

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

9 ‘‘(1) DISCOUNTED CASH PRICE.—The term ‘dis10 counted cash price’ means the charge that applies to 

11 an individual who pays cash, or cash equivalent, for 

12 an item or service. 

13 ‘‘(2) FEDERAL HEALTH CARE PROGRAM.—The 

14 term ‘Federal health care program’ has the meaning 

15 given such term in section 1128B. 

16 ‘‘(3) GROSS CHARGE.—The term ‘gross charge’ 

17 means the charge for an individual item or service 

18 that is reflected on a specified hospital’s or provider 

19 of service’s or supplier’s, as applicable, 

20 chargemaster, absent any discounts. 

21 ‘‘(4) GROUP HEALTH PLAN; GROUP HEALTH IN22 SURANCE COVERAGE; INDIVIDUAL HEALTH INSUR23 ANCE COVERAGE.—The terms ‘group health plan’, 

24 ‘group health insurance coverage’, and ‘individual 

25 health insurance coverage’ have the meaning given 


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1 such terms in section 2791 of the Public Health 

2 Service Act. 

3 ‘‘(5) PAYER-SPECIFIC NEGOTIATED CHARGE.— 

4 The term ‘payer-specific negotiated charge’ means 

5 the charge that a specified hospital or provider of 

6 services or supplier, as applicable, has negotiated 

7 with a third party payer for an item or service. 

8 ‘‘(6) SHOPPABLE SERVICE.—The term 

9 ‘shoppable service’ means a service that can be 

10 scheduled by a health care consumer in advance and 

11 includes all ancillary items and services customarily 

12 furnished as part of such service. 

13 ‘‘(7) SPECIFIED HOSPITAL.—The term ‘speci14 fied hospital’ means a hospital (as defined in section 

15 1861(e)), a critical access hospital (as defined in 

16 section 1861(mmm)(1)), or a rural emergency hos17 pital (as defined in section 1861(kkk)). 

18 ‘‘(8) THIRD PARTY PAYER.—The term ‘third 

19 party payer’ means an entity that is, by statute, con20 tract, or agreement, legally responsible for payment 

21 of a claim for a health care item or service.’’. 

22 (b) PHSA.— 

23 (1) IN GENERAL.—Section 2718 of the Public 

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1 ed by adding at the end the following new sub2 section: 

3 ‘‘(f) HOSPITAL TRANSPARENCY REQUIREMENT.— 

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

5 2026, each hospital shall comply with the price 

6 transparency requirement described in paragraph 

7 (2). 

8 ‘‘(2) REQUIREMENT DESCRIBED.— 

9 ‘‘(A) IN GENERAL.—For purposes of para10 graph (1), the price transparency requirement 

11 described in this paragraph is, with respect to 

12 a hospital, that such hospital, in accordance 

13 with a method and format established by the 

14 Secretary under subparagraph (C), compile and 

15 make public (without subscription and free of 

16 charge) for each year— 

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; 

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 


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1 subparagraph (B)) for as many of the 

2 Centers for Medicare & Medicaid 

3 Services-specified shoppable services 

4 that are furnished by the hospital, 

5 and as many additional hospital-se6 lected shoppable services (or all such 

7 additional services, if such hospital 

8 furnishes fewer than 300 shoppable 

9 services) as may be necessary for a 

10 combined total of at least 300 

11 shoppable services; and 

12 ‘‘(II) that includes, with respect 

13 to each Centers for Medicare & Med14 icaid Services-specified shoppable 

15 service that is not furnished by the 

16 hospital, an indication that such serv17 ice is not so furnished; and 

18 ‘‘(iii) an attestation that all informa19 tion made public pursuant to this subpara20 graph is complete and accurate. 

21 ‘‘(B) INFORMATION DESCRIBED.—For pur22 poses of subparagraph (A), the information de23 scribed in this subparagraph is, with respect to 

24 standard charges and prices, as applicable, 

25 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, as 

3 applicable, the Healthcare Common Proce4 dure Coding System code, the diagnosis-re5 lated group, the national drug code, cur6 rent procedure terminology codes, or other 

7 identifier used or approved by the Centers 

8 for Medicare & Medicaid Services. 

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

10 expressed as a dollar amount, for each 

11 such item or service, when provided in, as 

12 applicable, the inpatient setting and out13 patient department setting. 

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

15 applicable, expressed as a dollar amount, 

16 for each such item or service when pro17 vided in, as applicable, the inpatient set18 ting and outpatient department setting (or, 

19 in the case no discounted cash price is 

20 available for an item or service, the median 

21 cash price charged by the hospital to self22 pay individuals for such item or service 

23 when provided in such settings for the pre24 vious three years, expressed as a dollar 

25 amount, as well as, with respect to prices 


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1 made public pursuant to subparagraph 

2 (A)(ii), a link to a consumer-friendly docu3 ment that clearly explains the hospital’s 

4 charity care policy that includes, if applica5 ble, any sliding scale payment structure 

6 employed for determining charges for a 

7 self-pay individual). 

8 ‘‘(iv) The payer-specific negotiated 

9 charges, as applicable, clearly associated 

10 with the name of the third party payer and 

11 plan and expressed as a dollar amount, 

12 that apply to each such item or service 

13 when provided in, as applicable, the inpa14 tient setting and outpatient department 

15 setting. 

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

17 minimum negotiated charges, as applica18 ble, for each such item or service. 

19 ‘‘(vi) Any other additional information 

20 the Secretary may require for the purpose 

21 of improving the accuracy of, or enabling 

22 consumers to easily understand and com23 pare, standard charges and prices for an 

24 item or service, except information that is 


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1 duplicative of any other reporting require2 ment under this subsection. 

3 In the case of standard charges and prices for 

4 an item or service included as part of a bun5 dled, per diem, episodic, or other similar ar6 rangement, the information described in this 

7 subparagraph shall be made available as deter8 mined appropriate by the Secretary. 

9 ‘‘(C) UNIFORM METHOD AND FORMAT.— 

10 Not later than January 1, 2026, the Secretary 

11 shall establish a standard, uniform method and 

12 format for hospitals to use in compiling and 

13 making public standard charges pursuant to 

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

15 method and format for such hospitals to use in 

16 compiling and making public prices pursuant to 

17 subparagraph (A)(ii). Such methods and for18 mats— 

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

20 and format for making public standard 

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

22 ensure that such charges are made avail23 able in a machine-readable format (or a 

24 successor technology specified by the Sec25 retary); 


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

2 made available by the Centers for Medicare 

3 & Medicaid Services as of the date of the 

4 enactment of this subparagraph; 

5 ‘‘(iii) shall meet such standards as de6 termined appropriate by the Secretary in 

7 order to ensure the accessibility and 

8 usability of such charges and prices; and 

9 ‘‘(iv) shall be updated as determined 

10 appropriate by the Secretary, in consulta11 tion with stakeholders. 

12 ‘‘(3) MONITORING COMPLIANCE.—The Sec13 retary shall, through notice and comment rule14 making and in consultation with the Inspector Gen15 eral of the Department of Health and Human Serv16 ices, establish a process to monitor compliance with 

17 this subsection. Such process shall ensure that each 

18 hospital’s compliance with this subsection is re19 viewed not less frequently than once every 3 years. 

20 ‘‘(4) ENFORCEMENT.— 

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

23 of this subsection— 

24 ‘‘(i) not later than 30 days after the 

25 date on which the Secretary determines 


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1 such failure exists, the Secretary shall sub2 mit to such hospital a notification of such 

3 determination (which may include, as de4 termined appropriate by the Secretary, a 

5 request for a corrective action plan to com6 ply with such requirements); and 

7 ‘‘(ii) in the case of a hospital that 

8 does not receive a request for a corrective 

9 action plan as part of a notification sub10 mitted by the Secretary under clause (i)— 

11 ‘‘(I) the Secretary shall, not later 

12 than 45 days after such notification is 

13 sent, determine whether such hospital 

14 is in compliance with such require15 ments; and 

16 ‘‘(II) if the Secretary determines 

17 under subclause (I) that such hospital 

18 is not in compliance with such re19 quirements, the Secretary shall ei20 ther— 

21 ‘‘(aa) submit to such hos22 pital a request for a corrective 

23 action plan to comply with such 

24 requirements; or 


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1 ‘‘(bb) if the Secretary deter2 mines that such hospital has not 

3 taken meaningful actions to come 

4 into compliance since such notifi5 cation was sent, impose a civil 

6 monetary penalty in accordance 

7 with subparagraph (B). 

8 ‘‘(B) CIVIL MONETARY PENALTY.— 

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

10 other enforcement actions or penalties that 

11 may apply under another provision of law, 

12 a hospital that has received a request for 

13 a corrective action plan under clause (i) or 

14 (ii) of subparagraph (A) and fails to com15 ply with the requirements of this sub16 section by the date that is 45 days after 

17 such request is made, and a hospital with 

18 respect to which the Secretary has made a 

19 determination described in clause 

20 (ii)(II)(bb) of such subparagraph, shall be 

21 subject to a civil monetary penalty of an 

22 amount specified by the Secretary for each 

23 day (beginning with the day on which the 

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1 ments) during which such failure was on2 going. Such amount shall not exceed— 

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

4 30 or fewer beds, $300 per day (or, in 

5 the case of such a hospital that has 

6 been noncompliant with such require7 ments for a 1-year period or longer, 

8 beginning with the first day following 

9 such 1-year period, $400 per bed per 

10 day); 

11 ‘‘(II) in the case of a hospital 

12 with more than 30 beds but fewer 

13 than 101 beds, $12.50 per bed per 

14 day (or, in the case of such a hospital 

15 that has been noncompliant with such 

16 requirements for a 1-year period or 

17 longer, beginning with the first day 

18 following such 1-year period, $15 per 

19 bed per day); 

20 ‘‘(III) in the case of a hospital 

21 with more than 100 beds but fewer 

22 than 201 beds, $17.50 per bed per 

23 day (or, in the case of such a hospital 

24 that has been noncompliant with such 

25 requirements for a 1-year period or 


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1 longer, beginning with the first day 

2 following such 1-year period, $20 per 

3 bed per day); 

4 ‘‘(IV) in the case of a hospital 

5 with more than 200 beds but fewer 

6 than 501 beds, $20 per bed per day 

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

8 has been noncompliant with such re9 quirements for a 1-year period or 

10 longer, beginning with the first day 

11 following such 1-year period, $25 per 

12 bed per day); and 

13 ‘‘(V) in the case of a hospital 

14 with more than 500 beds, $25 per bed 

15 per day (or, in the case of such a hos16 pital that has been noncompliant with 

17 such requirements for a 1-year period 

18 or longer, beginning with the first day 

19 following such 1-year period, $35 per 

20 bed per day). 

21 ‘‘(ii) INCREASE AUTHORITY.—In ap22 plying this subparagraph with respect to 

23 violations occurring in 2027 or a subse24 quent year, the Secretary may through no25 tice and comment rulemaking increase— 


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

2 amount of any penalty applicable to a 

3 hospital under clause (i)(I); 

4 ‘‘(II) the limitations on the per 

5 bed per day amount of any penalty 

6 applicable under any of subclauses 

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

8 ‘‘(III) the amounts specified in 

9 clause (iii)(II). 

10 ‘‘(iii) PERSISTENT NONCOMPLI11 ANCE.— 

12 ‘‘(I) IN GENERAL.—In the case 

13 of a hospital (other than a hospital 

14 with 30 or fewer beds) that the Sec15 retary has determined to be knowingly 

16 and willfully noncompliant with the 

17 provisions of this subsection two or 

18 more times during a 1-year period, 

19 the Secretary may increase any pen20 alty otherwise applicable under this 

21 subparagraph by the amount specified 

22 in subclause (II) with respect to such 

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1 rective actions plans as the Secretary 

2 may specify. 

3 ‘‘(II) SPECIFIED AMOUNT.—For 

4 purposes of subclause (I), the amount 

5 specified in this subclause is, with re6 spect to a hospital— 

7 ‘‘(aa) with more than 30 

8 beds but fewer than 101 beds, an 

9 amount that is not less than 

10 $500,000 and not more than 

11 $1,000,000; 

12 ‘‘(bb) with more than 100 

13 beds but fewer than 301 beds, an 

14 amount that is greater than 

15 $1,000,000 and not more than 

16 $2,000,000; 

17 ‘‘(cc) with more than 300 

18 beds but fewer than 501 beds, an 

19 amount that is greater than 

20 $2,000,000 and not more than 

21 $4,000,000; and 

22 ‘‘(dd) with more than 500 

23 beds, and amount that is not less 

24 than $5,000,000 and not more 

25 than $10,000,000. 


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1 ‘‘(iv) AUTHORITY TO WAIVE OR RE2 DUCE PENALTY.— 

3 ‘‘(I) IN GENERAL.—Subject to 

4 subclause (II), the Secretary may 

5 waive any penalty, or reduce any pen6 alty by not more than 75 percent, oth7 erwise applicable under this subpara8 graph with respect to a hospital lo9 cated in a rural or underserved area if 

10 the Secretary certifies that imposition 

11 of such penalty would result in an im12 mediate threat to access to care for 

13 individuals in the service area of such 

14 hospital. 

15 ‘‘(II) LIMITATION ON APPLICA16 TION.—The Secretary may not elect 

17 to waive a penalty under subclause (I) 

18 with respect to a hospital more than 

19 once in a 6-year period and may not 

20 elect to reduce such a penalty with re21 spect to such a hospital more than 

22 once in such a period. Nothing in the 

23 preceding sentence shall be construed 

24 as prohibiting the Secretary from both 

25 waiving and reducing a penalty with 


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1 respect to a hospital during a 6-year 

2 period. 

3 ‘‘(v) PROVISION OF TECHNICAL AS4 SISTANCE.—The Secretary shall, to the ex5 tent practicable, provide technical assist6 ance relating to compliance with the provi7 sions of this section to hospitals requesting 

8 such assistance. 

9 ‘‘(vi) APPLICATION OF CERTAIN PRO10 VISIONS.—The provisions of section 1128A 

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

12 section) shall apply to a civil monetary 

13 penalty imposed under this subparagraph 

14 in the same manner as such provisions 

15 apply to a civil monetary penalty imposed 

16 under subsection (a) of such section. 

17 ‘‘(vii) NONDUPLICATION OF PEN18 ALTIES.—The Secretary may not subject a 

19 hospital to a civil monetary penalty under 

20 this subparagraph with respect to non21 compliance with the provisions of this sub22 section for a period if the Secretary has 

23 imposed a civil monetary penalty on such 

24 hospital under section 1899C of the Social 


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1 Security Act for failure to comply with the 

2 provisions of such section for such period. 

3 ‘‘(C) PUBLICATION OF HOSPITAL PRICE

4 TRANSPARENCY INFORMATION.—Beginning on 

5 January 1, 2026, the Secretary shall make pub6 licly available on the public website of the Cen7 ters for Medicare & Medicaid Services informa8 tion with respect to compliance with the re9 quirements of this subsection and enforcement 

10 activities undertaken by the Secretary under 

11 this subsection. Such information shall be up12 dated in real time and include— 

13 ‘‘(i) the number of reviews of compli14 ance with this subsection undertaken by 

15 the Secretary; 

16 ‘‘(ii) the number of notifications de17 scribed in subparagraph (A)(i) sent by the 

18 Secretary; 

19 ‘‘(iii) the identity of each hospital that 

20 was sent such a notification and a descrip21 tion of the nature of such hospital’s non22 compliance with this subsection; 

23 ‘‘(iv) the amount of any civil monetary 

24 penalty imposed on such hospital under 

25 subparagraph (B); 


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1 ‘‘(v) whether such hospital subse2 quently came into compliance with this 

3 subsection; 

4 ‘‘(vi) any waivers or reductions of 

5 penalties made pursuant to a certification 

6 by the Secretary under subparagraph 

7 (B)(iv), including— 

8 ‘‘(I) the name of any hospital 

9 that received such a waiver or reduc10 tion; 

11 ‘‘(II) the dollar amount of each 

12 such penalty so waived or reduced; 

13 and 

14 ‘‘(III) the rationale for the grant15 ing of each such waiver or reduction; 

16 and 

17 ‘‘(vii) any other information as deter18 mined by the Secretary. 

19 ‘‘(5) ENSURING ACCESSIBILITY THROUGH IM20 PLEMENTATION.—In implementing the amendments 

21 made by this section, the Secretary of Health and 

22 Human Services shall through rulemaking ensure 

23 that a hospital submitting charges and information 

24 pursuant to such amendments takes reasonable 

25 steps (as specified by the Secretary) to ensure the 


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1 accessibility of such charges and information to indi2 viduals with limited English proficiency. Such steps 

3 may include the hospital’s provision of interpretation 

4 services or the hospital’s provision of translations of 

5 charges and information. 

6 ‘‘(6) DEFINITIONS.—For purposes of this sub7 section: 

8 ‘‘(A) DISCOUNTED CASH PRICE.—The 

9 term ‘discounted cash price’ means the charge 

10 that applies to an individual who pays cash, or 

11 cash equivalent, for a hospital-furnished item or 

12 service. 

13 ‘‘(B) FEDERAL HEALTH CARE PROGRAM.— 

14 The term ‘Federal health care program’ has the 

15 meaning given such term in section 1128B of 

16 the Social Security Act. 

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

18 charge’ means the charge for an individual item 

19 or service that is reflected on a hospital’s 

20 chargemaster, absent any discounts. 

21 ‘‘(D) PAYER-SPECIFIC NEGOTIATED

22 CHARGE.—The term ‘payer-specific negotiated 

23 charge’ means the charge that a hospital has 

24 negotiated with a third party payer for an item 

25 or service. 


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1 ‘‘(E) SHOPPABLE SERVICE.—The term 

2 ‘shoppable service’ means a service that can be 

3 scheduled by a health care consumer in advance 

4 and includes all ancillary items and services 

5 customarily furnished as part of such service. 

6 ‘‘(F) THIRD PARTY PAYER.—The term 

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

8 statute, contract, or agreement, legally respon9 sible for payment of a claim for a health care 

10 item or service.’’. 

11 (2) CONFORMING AMENDMENTS.—Section 2718 

12 of the Public Health Service Act (42 U.S.C. 300gg– 

13 18) is amended— 

14 (A) in subsection (b)(3), by inserting 

15 ‘‘(other than the provisions of subsection (f))’’ 

16 after ‘‘this section’’; and 

17 (B) in subsection (e), by adding at the end 

18 the following new sentence: ‘‘The preceding pro19 visions of this subsection shall not apply begin20 ning on January 1, 2026.’’. 

21 (3) EFFECTIVE DATE.—The amendments made 

22 by this subsection shall apply beginning January 1, 

23 2026. 

24 (c) ACCESSIBILITY THROUGH IMPLEMENTATION.— 

25 In implementing the amendments made by this section, 


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1 the Secretary of Health and Human Services shall 

2 through rulemaking ensure that a hospital submitting 

3 charges and information pursuant to such amendments 

4 takes reasonable steps (as specified by the Secretary) to 

5 ensure the accessibility of such charges and information 

6 to individuals with limited English proficiency. Such steps 

7 may include the hospital’s provision of interpretation serv8 ices or the hospital’s provision of translations of charges 

9 and information. 

10 SEC. 102. CLINICAL DIAGNOSTIC LABORATORY TEST PRICE 

11 TRANSPARENCY. 

12 Section 1846 of the Social Security Act (42 U.S.C. 

13 1395w–2) is amended— 

14 (1) in the header, by inserting ‘‘AND ADDI15 TIONAL REQUIREMENTS’’ after ‘‘SANCTIONS’’; 

16 and 

17 (2) by adding at the end the following new sub18 section: 

19 ‘‘(c) PRICE TRANSPARENCY REQUIREMENT.— 

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

21 2026, any applicable laboratory that receives pay22 ment under this title for furnishing any specified 

23 clinical diagnostic laboratory test under this title 

24 shall— 


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

2 website the information described in paragraph 

3 (2) with respect to each such specified clinical 

4 diagnostic laboratory test that such laboratory 

5 so furnishes; and 

6 ‘‘(B) ensure that such information is up7 dated not less frequently than annually. 

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

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

10 paragraph is, with respect to an applicable labora11 tory and a specified clinical diagnostic laboratory 

12 test, the following: 

13 ‘‘(A) The discounted cash price for such 

14 test (or, if no such price exists, the gross 

15 charge for such test). 

16 ‘‘(B) The deidentified minimum payer-spe17 cific negotiated charge for such test. 

18 ‘‘(C) The deidentified maximum payer-spe19 cific negotiated charge between such laboratory 

20 and any third party payer for such test. 

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

22 later than January 1, 2026, the Secretary shall es23 tablish a standard, uniform method and format for 

24 applicable laboratories to use in compiling and makVerDate Sep 11 2014 05:20 Sep 10, 2023 Jkt 039200 PO 00000 Frm 00040 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 ing public information pursuant to paragraph (1). 

2 Such method and format— 

3 ‘‘(A) may be similar to any template made 

4 available by the Centers for Medicare & Med5 icaid Services (as described in section 

6 1899C(a)(2)(C)(ii)); 

7 ‘‘(B) shall meet such standards as deter8 mined appropriate by the Secretary in order to 

9 ensure the accessibility and usability of such in10 formation; and 

11 ‘‘(C) shall be updated as determined ap12 propriate by the Secretary, in consultation with 

13 stakeholders. 

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

15 Any price or rate for a specified clinical diagnostic 

16 laboratory test available to be furnished by an appli17 cable laboratory made publicly available in accord18 ance with paragraph (1) shall include the price or 

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

20 (such as specimen collection services) that would 

21 normally be furnished by such laboratory as part of 

22 such test, as specified by the Secretary. 

23 ‘‘(5) ENFORCEMENT.— 


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

2 Secretary determines that an applicable labora3 tory is not in compliance with paragraph (1)— 

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

5 determination, the Secretary shall notify 

6 such laboratory of such determination; and 

7 ‘‘(ii) if such laboratory continues to 

8 fail to comply with such paragraph after 

9 the date that is 90 days after such notifi10 cation is sent, the Secretary may impose a 

11 civil monetary penalty in an amount not to 

12 exceed $300 for each (beginning with the 

13 day on which the Secretary first deter14 mined that such laboratory was failing to 

15 comply with such paragraph) during which 

16 such failure is ongoing. 

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

18 this paragraph with respect to violations occur19 ring in 2027 or a subsequent year, the Sec20 retary may through notice and comment rule21 making increase the per day limitation on civil 

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

23 ‘‘(C) APPLICATION OF CERTAIN PROVI24 SIONS.—The provisions of section 1128A (other 

25 than subsections (a) and (b) of such section) 


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1 shall apply to a civil monetary penalty imposed 

2 under this paragraph in the same manner as 

3 such provisions apply to a civil monetary pen4 alty imposed under subsection (a) of such sec5 tion. 

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 applicable labora10 tories requesting such assistance. 

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

12 ‘‘(A) APPLICABLE LABORATORY.—The 

13 term ‘applicable laboratory’ has the meaning 

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

15 Code of Federal Regulations (or a successor 

16 regulation), except that such term does not in17 clude a laboratory with respect to which stand18 ard charges and prices for specified clinical di19 agnostic laboratory tests furnished by such lab20 oratory are made available by a hospital pursu21 ant to section 1899C or section 2718(f) of the 

22 Public Health Service Act. 

23 ‘‘(B) DISCOUNTED CASH PRICE.—The 

24 term ‘discounted cash price’ means the charge 


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1 that applies to an individual who pays cash, or 

2 cash equivalent, for an item or service. 

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

4 charge’ means the charge for an individual item 

5 or service that is reflected on an applicable lab6 oratory’s chargemaster, absent any discounts. 

7 ‘‘(D) PAYER-SPECIFIC NEGOTIATED

8 CHARGE.—The term ‘payer-specific negotiated 

9 charge’ means the charge that an applicable 

10 laboratory has negotiated with a third party 

11 payer for an item or service. 

12 ‘‘(E) SPECIFIED CLINICAL DIAGNOSTIC

13 LABORATORY TEST.—the term ‘specified clinical 

14 diagnostic laboratory test’ means a clinical di15 agnostic laboratory test that is included on the 

16 list of shoppable services specified by the Cen17 ters for Medicare & Medicaid Services (as de18 scribed in section 1899C(a)(2)(A)(ii)(I)), other 

19 than such a test that is only available to be fur20 nished by a single provider of services or sup21 plier. 

22 ‘‘(F) THIRD PARTY PAYER.—The term 

23 ‘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. 103. IMAGING PRICE TRANSPARENCY. 

4 Section 1899C of the Social Security Act, as added 

5 by section 101, is amended— 

6 (1) by redesignating subsection (b) as sub7 section (c); 

8 (2) by inserting after subsection (a) the fol9 lowing new subsection: 

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

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

12 2028, each provider of services and supplier that re13 ceives payment under this title for furnishing a spec14 ified imaging service, other than such a provider or 

15 supplier with respect to which standard charges and 

16 prices for such services furnished by such provider 

17 or supplier are made available by a hospital pursu18 ant to section 1899C or section 2718(f) of the Pub19 lic Health Service Act, 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) The discounted cash price for such 

9 service (or, if no such price exists, the gross 

10 charge for such service). 

11 ‘‘(B) If required by the Secretary, the 

12 deidentified minimum payer-specific negotiated 

13 charge for such service and the deidentified 

14 maximum payer-specific negotiated charge for 

15 such service. 

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

17 later than January 1, 2028, the Secretary shall es18 tablish a standard, uniform method and format for 

19 providers of services and suppliers to use in making 

20 public information described in paragraph (2). Any 

21 such method and format— 

22 ‘‘(A) may be similar to any template made 

23 available by the Centers for Medicare & Med24 icaid Services (as described in section 

25 1899C(a)(2)(C)(ii)); 


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1 ‘‘(B) shall meet such standards as deter2 mined appropriate by the Secretary in order to 

3 ensure the accessibility and usability of such in4 formation; and 

5 ‘‘(C) shall be updated as determined ap6 propriate by the Secretary, in consultation with 

7 stakeholders. 

8 ‘‘(4) MONITORING COMPLIANCE.—The Sec9 retary shall, through notice and comment rule10 making and in consultation with the Inspector Gen11 eral of the Department of Health and Human Serv12 ices, establish a process to monitor compliance with 

13 this subsection. 

14 ‘‘(5) ENFORCEMENT.— 

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

16 Secretary determines that a provider of services 

17 or supplier is not in compliance with paragraph 

18 (1)— 

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

20 determination, the Secretary shall notify 

21 such provider or supplier of such deter22 mination; 

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

24 such provider or supplier shall submit to 

25 the Secretary, not later than 45 days after 


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1 the date of such request, a corrective ac2 tion plan to comply with such paragraph; 

3 and 

4 ‘‘(iii) if such provider or supplier con5 tinues to fail to comply with such para6 graph after the date that is 90 days after 

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

8 such a provider or supplier that has sub9 mitted a corrective action plan described in 

10 clause (ii) in response to a request so de11 scribed, after the date that is 90 days after 

12 such submission), the Secretary may im13 pose a civil monetary penalty in an amount 

14 not to exceed $300 for each day (beginning 

15 with the day on which the Secretary first 

16 determined that such provider or supplier 

17 was failing to comply with such paragraph) 

18 during which such failure to comply or fail19 ure to submit is ongoing. 

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

21 this paragraph with respect to violations occur22 ring in 2029 or a subsequent year, the Sec23 retary may through notice and comment rule24 making increase the amount of the civil mone25 tary penalty under subparagraph (A)(iii). 


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1 ‘‘(C) APPLICATION OF CERTAIN PROVI2 SIONS.—The provisions of section 1128A (other 

3 than subsections (a) and (b) of such section) 

4 shall apply to a civil monetary penalty imposed 

5 under this paragraph in the same manner as 

6 such provisions apply to a civil monetary pen7 alty imposed under subsection (a) of such sec8 tion. 

9 ‘‘(D) AUTHORITY TO WAIVE OR REDUCE

10 PENALTY.— 

11 ‘‘(i) IN GENERAL.—Subject to clause 

12 (ii), the Secretary may waive or reduce any 

13 penalty otherwise applicable with respect to 

14 a provider of services or supplier under 

15 this subparagraph if the Secretary certifies 

16 that imposition of such penalty would re17 sult in an immediate threat to access to 

18 care for individuals in the service area of 

19 such provider or supplier. 

20 ‘‘(ii) LIMITATION.—The Secretary 

21 may not elect to waive or reduce a penalty 

22 under clause (i) with respect to a specific 

23 provider of services or supplier more than 

24 3 times. 


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1 ‘‘(E) PROVISION OF TECHNICAL ASSIST2 ANCE.—The Secretary shall, to the extent prac3 ticable, provide technical assistance relating to 

4 compliance with the provisions of this sub5 section to providers of services and suppliers re6 questing such assistance. 

7 ‘‘(F) CLARIFICATION OF NONAPPLICA8 BILITY OF OTHER ENFORCEMENT PROVI9 SIONS.—Notwithstanding any other provision of 

10 this title, this paragraph shall be the sole 

11 means of enforcing the provisions of this sub12 section.’’; and 

13 (3) in subsection (c), as so redesignated by 

14 paragraph (1)— 

15 (A) by redesignating paragraph (8) as 

16 paragraph (9); and 

17 (B) by inserting after paragraph (7) the 

18 following new paragraph: 

19 ‘‘(8) SPECIFIED IMAGING SERVICE.—the term 

20 ‘specified imaging service’ means an imaging service 

21 that is a Centers for Medicare & Medicaid Services22 specified shoppable service (as described in sub23 section (a)(2)(A)(ii)(I)).’’. 


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1 SEC. 104. AMBULATORY SURGICAL CENTER PRICE TRANS2 PARENCY. 

3 Section 1834 of the Social Security Act (42 U.S.C. 

4 1395m) is amended by adding at the end the following 

5 new subsection: 

6 ‘‘(aa) AMBULATORY SURGICAL CENTER PRICE

7 TRANSPARENCY.— 

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

9 2026, each specified ambulatory surgical center that 

10 receives payment under this title for furnishing 

11 items and services shall comply with the price trans12 parency requirement described in paragraph (2). 

13 ‘‘(2) REQUIREMENT DESCRIBED.— 

14 ‘‘(A) IN GENERAL.—For purposes of para15 graph (1), the price transparency requirement 

16 described in this subsection is, with respect to 

17 a specified ambulatory surgical center, that 

18 such surgical center in accordance with a meth19 od and format established by the Secretary 

20 under subparagraph (C), compile and make 

21 public (without subscription and free of 

22 charge), for each year— 

23 ‘‘(i) all of the ambulatory surgical 

24 center’s standard charges (including the 

25 information described in subparagraph 


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1 (B)) for each item and service furnished by 

2 such surgical center; 

3 ‘‘(ii) information on the ambulatory 

4 surgical center’s prices (including the in5 formation described in subparagraph (B)) 

6 for as many of the Centers for Medicare & 

7 Medicaid Services-specified shoppable serv8 ices that are furnished by such surgical 

9 center, and as many additional ambulatory 

10 surgical center-selected shoppable services 

11 (or all such additional services, if such sur12 gical center furnishes fewer than 300 

13 shoppable services) as may be necessary 

14 for a combined total of at least 300 

15 shoppable services; and 

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

17 Medicare & Medicaid Services-specified 

18 shoppable service that is not furnished by 

19 the ambulatory surgical center, an indica20 tion that such service is not so furnished. 

21 ‘‘(B) INFORMATION DESCRIBED.—For pur22 poses of subparagraph (A), the information de23 scribed in this subparagraph is, with respect to 

24 standard charges and prices (as applicable) 


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1 made public by a specified ambulatory surgical 

2 center, the following: 

3 ‘‘(i) A plain language description of 

4 each item or service, accompanied by, as 

5 applicable, the Healthcare Common Proce6 dure Coding System code, the diagnosis-re7 lated group, the national drug code, or 

8 other identifier used or approved by the 

9 Centers for Medicare & Medicaid Services. 

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

11 expressed as a dollar amount, for each 

12 such item or service. 

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

14 applicable, expressed as a dollar amount, 

15 for each such item or service (or, in the 

16 case no discounted cash price is available 

17 for an item or service, the median cash 

18 price charged to self-pay individuals for 

19 such item or service for the previous three 

20 years, expressed as a dollar amount). 

21 ‘‘(iv) The current payer-specific nego22 tiated charges, clearly associated with the 

23 name of the third party payer and plan 

24 and expressed as a dollar amount, that ap25 plies to each such item or service. 


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

2 minimum negotiated charges, as applica3 ble, for each such item or service. 

4 ‘‘(vi) Any other additional information 

5 the Secretary may require for the purpose 

6 of improving the accuracy of, or enabling 

7 consumers to easily understand and com8 pare, standard charges and prices for an 

9 item or service, except information that is 

10 duplicative of any other reporting require11 ment under this subsection. 

12 ‘‘(C) UNIFORM METHOD AND FORMAT.— 

13 Not later than January 1, 2026, the Secretary 

14 shall establish a standard, uniform method and 

15 format for specified ambulatory surgical centers 

16 to use in making public standard charges and 

17 a standard, uniform method and format for 

18 such centers to use in making public prices pur19 suant to subparagraph (A). Any such method 

20 and format— 

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

22 made public by an ambulatory surgical 

23 center, ensure that such charges are made 

24 available in a machine-readable format (or 

25 successor technology); 


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

2 made available by the Centers for Medicare 

3 & Medicaid Services as of the date of the 

4 enactment of this paragraph; 

5 ‘‘(iii) shall meet such standards as de6 termined appropriate by the Secretary in 

7 order to ensure the accessibility and 

8 usability of such charges and prices; and 

9 ‘‘(iv) shall be updated as determined 

10 appropriate by the Secretary, in consulta11 tion with stakeholders. 

12 ‘‘(3) MONITORING COMPLIANCE.—The Sec13 retary shall, through notice and comment rule14 making and in consultation with the Inspector Gen15 eral of the Department of Health and Human Serv16 ices, establish a process to monitor compliance with 

17 this subsection. Such process shall ensure that each 

18 specified ambulatory surgical center’s compliance 

19 with this subsection is reviewed not less frequently 

20 than once every 3 years. 

21 ‘‘(4) ENFORCEMENT.— 

22 ‘‘(A) IN GENERAL.—In the case of a speci23 fied ambulatory surgical center that fails to 

24 comply with the requirements of this sub25 section— 


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1 ‘‘(i) the Secretary shall notify such 

2 ambulatory surgical center of such failure 

3 not later than 30 days after the date on 

4 which the Secretary determines such fail5 ure exists; and 

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

7 the ambulatory surgical center shall submit 

8 to the Secretary, not later than 45 days 

9 after the date of such request, a corrective 

10 action plan to comply with such require11 ments. 

12 ‘‘(B) CIVIL MONETARY PENALTY.— 

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

14 other enforcement actions or penalties that 

15 may apply under another provision of law, 

16 a specified ambulatory surgical center that 

17 has received a notification under subpara18 graph (A)(i) and fails to comply with the 

19 requirements of this subsection by the date 

20 that is 90 days after such notification (or, 

21 in the case of an ambulatory surgical cen22 ter that has submitted a corrective action 

23 plan described in subparagraph (A)(ii) in 

24 response to a request so described, by the 

25 date that is 90 days after such submission) 


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1 shall be subject to a civil monetary penalty 

2 of an amount specified by the Secretary for 

3 each subsequent day during which such 

4 failure is ongoing (not to exceed $300 per 

5 day). 

6 ‘‘(ii) INCREASE AUTHORITY.—In ap7 plying this subparagraph with respect to 

8 violations occurring in 2027 or a subse9 quent year, the Secretary may through no10 tice and comment rulemaking increase the 

11 limitation on the per day amount of any 

12 penalty applicable to a specified ambula13 tory surgical center under clause (i). 

14 ‘‘(iii) APPLICATION OF CERTAIN PRO15 VISIONS.—The provisions of section 1128A 

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

17 section) shall apply to a civil monetary 

18 penalty imposed under this subparagraph 

19 in the same manner as such provisions 

20 apply to a civil monetary penalty imposed 

21 under subsection (a) of such section. 

22 ‘‘(iv) AUTHORITY TO WAIVE OR RE23 DUCE PENALTY.— 

24 ‘‘(I) IN GENERAL.—Subject to 

25 subclause (II), the Secretary may 


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1 waive any penalty, or reduce any pen2 alty by not more than 75 percent, oth3 erwise applicable under this subpara4 graph with respect to a specified am5 bulatory surgical center located in a 

6 rural or underserved area if the Sec7 retary certifies that imposition of such 

8 penalty would result in an immediate 

9 threat to access to care for individuals 

10 in the service area of such surgical 

11 center. 

12 ‘‘(II) LIMITATION ON APPLICA13 TION.—The Secretary may not elect 

14 to waive a penalty under subclause (I) 

15 with respect to a specified ambulatory 

16 surgical center more than once in a 6- 

17 year period and may not elect to re18 duce such a penalty with respect to 

19 such a surgical center more than once 

20 in such a period. Nothing in the pre21 ceding sentence shall be construed as 

22 prohibiting the Secretary from both 

23 waiving and reducing a penalty with 

24 respect to a specified surgical center 

25 during a 6-year period. 


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1 ‘‘(5) DEFINITIONS.—For purposes of this sec2 tion: 

3 ‘‘(A) DISCOUNTED CASH PRICE.—The 

4 term ‘discounted cash price’ means the charge 

5 that applies to an individual who pays cash, or 

6 cash equivalent, for a item or service furnished 

7 by an ambulatory surgical center. 

8 ‘‘(B) FEDERAL HEALTH CARE PROGRAM.— 

9 The term ‘Federal health care program’ has the 

10 meaning given such term in section 1128B. 

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

12 charge’ means the charge for an individual item 

13 or service that is reflected on a specified sur14 gical center’s chargemaster, absent any dis15 counts. 

16 ‘‘(D) GROUP HEALTH PLAN; GROUP

17 HEALTH INSURANCE COVERAGE; INDIVIDUAL

18 HEALTH INSURANCE COVERAGE.—The terms 

19 ‘group health plan’, ‘group health insurance 

20 coverage’, and ‘individual health insurance cov21 erage’ have the meaning given such terms in 

22 section 2791 of the Public Health Service Act. 

23 ‘‘(E) PAYER-SPECIFIC NEGOTIATED

24 CHARGE.—The term ‘payer-specific negotiated 

25 charge’ means the charge that a specified surVerDate Sep 11 2014 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00059 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 gical center has negotiated with a third party 

2 payer for an item or service. 

3 ‘‘(F) SHOPPABLE SERVICE.—The term 

4 ‘shoppable service’ means a service that can be 

5 scheduled by a health care consumer in advance 

6 and includes all ancillary items and services 

7 customarily furnished as part of such service. 

8 ‘‘(G) SPECIFIED AMBULATORY SURGICAL

9 CENTER.—The term ‘specified ambulatory sur10 gical center’ means an ambulatory surgical cen11 ter with respect to which a hospital (or any per12 son with an ownership or control interest (as 

13 defined in section 1124(a)(3)) in a hospital) is 

14 a person with an ownership or control interest 

15 (as so defined). 

16 ‘‘(H) THIRD PARTY PAYER.—The term 

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

18 statute, contract, or agreement, legally respon19 sible for payment of a claim for a health care 

20 item or service.’’. 

21 SEC. 105. HEALTH COVERAGE PRICE TRANSPARENCY. 

22 (a) PRICE TRANSPARENCY REQUIREMENTS.— 

23 (1) IRC.— 


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1 (A) IN GENERAL.—Section 9819 of the In2 ternal Revenue Code of 1986 is amended to 

3 read as follows: 

4 ‘‘SEC. 9819. TRANSPARENCY IN COVERAGE. 

5 ‘‘(a) COST-SHARING TRANSPARENCY.— 

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

7 on or after January 1, 2026, a group health plan 

8 shall permit a participant or beneficiary to learn the 

9 amount of cost-sharing (including deductibles, co10 payments, and coinsurance) under the participant or 

11 beneficiary’s plan that the participant or beneficiary 

12 would be responsible for paying with respect to the 

13 furnishing of a specific item or service by a provider 

14 in a timely manner upon the request of the partici15 pant or beneficiary. At a minimum, such information 

16 shall include the information specified in paragraph 

17 (2) and shall be made available to such participant 

18 or beneficiary through a self-service tool that meets 

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

20 of such participant or beneficiary, through a paper 

21 disclosure or phone or other electronic disclosure (as 

22 selected by such participant or beneficiary and pro23 vided at no cost to such participant or beneficiary) 

24 that meets such requirements as the Secretary may 

25 specify. 


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

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

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

4 which benefits are available under a group health 

5 plan furnished by a health care provider to a partici6 pant or beneficiary of such plan, the following: 

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

8 provider with respect to such item or service, 

9 the in-network rate (as defined in subsection 

10 (c)) for such item or service. 

11 ‘‘(B) If such provider is not a participating 

12 provider with respect to such item or service, 

13 the maximum allowed amount or other dollar 

14 amount that such plan or coverage will recog15 nize as payment for such item or service, along 

16 with a notice that such participant or bene17 ficiary may be liable for additional charges. 

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

19 (including deductibles, copayments, and coin20 surance) that the participant or beneficiary will 

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

22 case such item or service is to be furnished by 

23 a provider described in subparagraph (B), shall 

24 be calculated using the maximum allowed 


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1 amount or other dollar amount described in 

2 such subparagraph). 

3 ‘‘(D) The amount the participant or bene4 ficiary has already accumulated with respect to 

5 any deductible or out of pocket maximum under 

6 the plan (broken down, in the case separate 

7 deductibles or maximums apply to separate par8 ticipants and beneficiaries enrolled in the plan, 

9 by such separate deductibles or maximums, in 

10 addition to any cumulative deductible or max11 imum). 

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

13 frequency or volume limitations with respect to 

14 such item or service (excluding medical neces15 sity determinations), the amount that such par16 ticipant or beneficiary has accrued towards such 

17 limitation with respect to such item or service. 

18 ‘‘(F) Any prior authorization, concurrent 

19 review, step therapy, fail first, or similar re20 quirements applicable to coverage of such item 

21 or service under such plan. 

22 ‘‘(G) Any shared savings (such as any 

23 credit, payment, or other benefit provided by 

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1 nished by such provider known at the time such 

2 request is made. 

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 (or 

8 successor technology specified by the Sec9 retary); 

10 ‘‘(B) provides for real-time responses to re11 quests described in paragraph (1); 

12 ‘‘(C) is updated in a manner such that in13 formation provided through such tool is timely 

14 and accurate at the time such request is made; 

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

16 with respect to an item or service furnished 

17 by— 

18 ‘‘(i) a specific provider that is a par19 ticipating provider with respect to such 

20 item or service; 

21 ‘‘(ii) all providers that are partici22 pating providers with respect to such item 

23 or service; or 


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1 ‘‘(iii) a provider in a relevant geo2 graphic region that is not described in 

3 clause (i) or (ii); 

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

5 made with respect to an item or service through 

6 use of the billing code for such item or service 

7 or through use of a descriptive term for such 

8 item or service; and 

9 ‘‘(F) meets any other requirement deter10 mined appropriate by the Secretary to ensure 

11 the accessibility and usability of information 

12 provided through such tool. 

13 The Secretary may require such tool, as a condition 

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

15 billing codes to a single descriptive term if the Sec16 retary determines that the billing codes to be so 

17 linked correspond to similar items and services. 

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

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

20 on or after January 1, 2026, each group health plan 

21 (other than a grandfathered health plan (as defined 

22 in section 1251(e) of the Patient Protection and Af23 fordable Care Act)) shall, for each month, not later 

24 than the tenth day of such month, make available to 

25 the public the rate and payment information deVerDate Sep 11 2014 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00065 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 scribed in paragraph (2) in accordance with para2 graph (3). 

3 ‘‘(2) RATE AND PAYMENT INFORMATION DE4 SCRIBED.—For purposes of paragraph (1), the rate 

5 and payment information described in this para6 graph is, with respect to a group health plan, the 

7 following: 

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

9 (other than a drug) for which benefits are avail10 able under such plan, the in-network rate (ex11 pressed as a dollar amount) in effect as of the 

12 date on which such information is made public 

13 with each provider that is a participating pro14 vider with respect to such item or service. 

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

16 by national drug code) for which benefits are 

17 available under such plan— 

18 ‘‘(i) the in-network rate (expressed as 

19 a dollar amount) in effect as of the first 

20 day of the month in which such informa21 tion is made public with each provider that 

22 is a participating provider with respect to 

23 such drug; and 

24 ‘‘(ii) the average amount paid by such 

25 plan (net of rebates, discounts, and price 


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1 concessions) for such drug dispensed or 

2 administered during the 90-day period be3 ginning 180 days before such date of pub4 lication to each provider that was a partici5 pating provider with respect to such drug, 

6 broken down by each such provider, other 

7 than such an amount paid to a provider 

8 that, during such period, submitted fewer 

9 than 20 claims for such drug to such plan. 

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

11 for which benefits are available under such 

12 plan, the amount billed, and the amount al13 lowed by the plan, for each such item or service 

14 furnished during the 90-day period specified in 

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

16 participating provider with respect to such item 

17 or service, broken down by each such provider. 

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

19 payment information required to be made available 

20 under this subsection shall be so made available in 

21 dollar amounts through separate machine-readable 

22 files (and any successor technology, such as applica23 tion program interface technology, determined ap24 propriate by the Secretary) corresponding to the in25 formation described in each of subparagraphs (A) 


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1 through (C) of paragraph (2) that meet such re2 quirements as specified by the Secretary through 

3 subregulatory guidance. Such requirements shall en4 sure that such files are limited to an appropriate 

5 size, do not include disclosure of unnecessary dupli6 cative information contained in other files made 

7 available under this subsection, are made available 

8 in a widely available format through a publicly avail9 able website that allows for information contained in 

10 such files to be compared across group health plans 

11 and group or individual health insurance coverage, 

12 and are accessible to individuals at no cost and with13 out the need to establish a user account or provide 

14 other credentials. 

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

16 plan shall make available to the public instructions 

17 written in plain language explaining how individuals 

18 may search for information described in paragraph 

19 (2) in files submitted in accordance with paragraph 

20 (3). The Secretary shall develop and publish through 

21 subregulatory guidance a template that such a plan 

22 may use in developing instructions for purposes of 

23 the preceding sentence. 

24 ‘‘(5) SUMMARY.—For each plan year beginning 

25 on or after January 1, 2026, each group health plan 


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1 shall make public a data file, in a manner that en2 sures that such file may be easily downloaded and 

3 read by standard spreadsheet software and that 

4 meets such requirements as established by the Sec5 retary, containing a summary of all rate and pay6 ment information made public by such plan with re7 spect to such plan during such plan year. Such file 

8 shall include the following: 

9 ‘‘(A) The mean, median, and interquartile 

10 range of the in-network rate, and the amount 

11 allowed for an item or service when not fur12 nished by a participating provider, in effect as 

13 of the first day of such plan year for each item 

14 or service (identified by payer identifier ap15 proved or used by the Centers for Medicare & 

16 Medicaid Services) for which benefits are avail17 able under the plan, broken down by the type 

18 of provider furnishing the item or service and 

19 by the geographic area in which such item or 

20 service is furnished. 

21 ‘‘(B) Trends in payment rates for such 

22 items and services over such plan year, includ23 ing an identification of instances in which such 

24 rates have increased, decreased, or remained 

25 the same. 


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1 ‘‘(C) The name of such plan, a description 

2 of the type of network of participating providers 

3 used by such plan, and a description of whether 

4 such plan is self-insured or fully-insured. 

5 ‘‘(D) For each item or service which is 

6 paid as part of a bundled rate— 

7 ‘‘(i) a description of the formulae, 

8 pricing methodologies, or other information 

9 used to calculate the payment rate for such 

10 bundle; and 

11 ‘‘(ii) a list of the items and services 

12 included in such bundle. 

13 ‘‘(E) The percentage of items and services 

14 that are paid for on a fee-for-service basis and 

15 the percentage of items and services that are 

16 paid for as part of a bundled rate, capitated 

17 payment rate, or other alternative payment 

18 model. 

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

20 shall post, along with rate and payment information 

21 made public by such plan, an attestation that such 

22 information is complete and accurate. 

23 ‘‘(c) ACCESSIBILITY.—A group health plan shall take 

24 reasonable steps (as specified by the Secretary) to ensure 

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1 scribed in subsection (a), and rate and payment informa2 tion made public under subsection (b), is provided in plain, 

3 easily understandable language and that interpretation, 

4 translations, and assistive services are provided to those 

5 with limited English proficiency and those with disabil6 ities. 

7 ‘‘(d) DEFINITIONS.—In this section: 

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

9 ‘participating provider’ means, with respect to an 

10 item or service and a group health plan, a physician 

11 or other health care provider who is acting within 

12 the scope of practice of that provider’s license or cer13 tification under applicable State law and who has a 

14 contractual relationship with the plan, respectively, 

15 for furnishing such item or service under the plan, 

16 and includes facilities, respectively. 

17 ‘‘(2) PROVIDER.—The term ‘provider’ includes 

18 a health care facility. 

19 ‘‘(3) IN-NETWORK RATE.—The term ‘in-net20 work rate’ means, with respect to a group health 

21 plan and an item or service furnished by a provider 

22 that is a participating provider with respect to such 

23 plan and item or service, the contracted rate (re24 flected as a dollar amount) in effect between such 

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1 gardless of whether such rate is calculated based on 

2 a set amount, a fee schedule, or an amount derived 

3 from another amount, or a formula, or other meth4 od.’’. 

5 (B) CLERICAL AMENDMENT.—The item re6 lating to section 9819 of the table of sections 

7 for subchapter B of chapter 100 of the Internal 

8 Revenue Code of 1986 is amended to read as 

9 follows: 

‘‘Sec. 9819. Transparency in coverage.’’. 

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

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

12 amended to read as follows: 

13 ‘‘SEC. 2799A–4. TRANSPARENCY IN COVERAGE. 

14 ‘‘(a) COST-SHARING TRANSPARENCY.— 

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

16 on or after January 1, 2026, a group health plan 

17 and a health insurance issuer offering group or indi18 vidual health insurance coverage shall permit an in19 dividual enrolled under such plan or coverage to 

20 learn the amount of cost-sharing (including 

21 deductibles, copayments, and coinsurance) under the 

22 individual’s plan or coverage that the individual 

23 would be responsible for paying with respect to the 

24 furnishing of a specific item or service by a provider 

25 in a timely manner upon the request of the indiVerDate Sep 11 2014 05:20 Sep 10, 2023 Jkt 039200 PO 00000 Frm 00072 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 vidual. At a minimum, such information shall in2 clude the information specified in paragraph (2) and 

3 shall be made available to such individual through a 

4 self-service tool that meets the requirements of para5 graph (3) or, at the option of such individual, 

6 through a paper disclosure or phone or other elec7 tronic disclosure (as selected by such individual and 

8 provided at no cost to such individual) that meets 

9 such requirements as the Secretary may specify. 

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

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

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

13 which benefits are available under a group health 

14 plan or group or individual health insurance cov15 erage furnished by a health care provider to an indi16 vidual enrolled under such plan or coverage, the fol17 lowing: 

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

19 provider with respect to such item or service, 

20 the in-network rate (as defined in subsection 

21 (c)) for such item or service. 

22 ‘‘(B) If such provider is not a participating 

23 provider with respect to such item or service, 

24 the maximum allowed amount or other dollar 

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1 nize as payment for such item or service, along 

2 with a notice that such individual may be liable 

3 for additional charges. 

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

5 (including deductibles, copayments, and coin6 surance) that the individual will incur for such 

7 item or service (which, in the case such item or 

8 service is to be furnished by a provider de9 scribed in subparagraph (B), shall be calculated 

10 using the maximum allowed amount or other 

11 dollar amount described in such subparagraph). 

12 ‘‘(D) The amount the individual has al13 ready accumulated with respect to any deduct14 ible or out of pocket maximum under the plan 

15 or coverage (broken down, in the case separate 

16 deductibles or maximums apply to separate in17 dividuals enrolled in the plan or coverage, by 

18 such separate deductibles or maximums, in ad19 dition to any cumulative deductible or max20 imum). 

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

22 frequency or volume limitations with respect to 

23 such item or service (excluding medical neces24 sity determinations), the amount that such indiVerDate Sep 11 2014 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00074 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 vidual has accrued towards such limitation with 

2 respect to such item or service. 

3 ‘‘(F) Any prior authorization, concurrent 

4 review, step therapy, fail first, or similar re5 quirements applicable to coverage of such item 

6 or service under such plan or coverage. 

7 ‘‘(G) Any shared savings (such as any 

8 credit, payment, or other benefit provided by 

9 such plan or issuer) available to the individual 

10 with respect to such item or service furnished 

11 by such provider known at the time such re12 quest is made. 

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

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

15 group health plan or health insurance issuer offering 

16 group or individual health insurance coverage meets 

17 the requirements of this paragraph if such tool— 

18 ‘‘(A) is based on an internet website (or 

19 successor technology specified by the Sec20 retary); 

21 ‘‘(B) provides for real-time responses to re22 quests described in paragraph (1); 

23 ‘‘(C) is updated in a manner such that in24 formation provided through such tool is timely 

25 and accurate at the time such request is made; 


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•HR 5378 IH

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

2 with respect to an item or service furnished 

3 by— 

4 ‘‘(i) a specific provider that is a par5 ticipating provider with respect to such 

6 item or service; 

7 ‘‘(ii) all providers that are partici8 pating providers with respect to such item 

9 or service; or 

10 ‘‘(iii) a provider in a relevant geo11 graphic region that is not described in 

12 clause (i) or (ii); 

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

14 made with respect to an item or service through 

15 use of the billing code for such item or service 

16 or through use of a descriptive term for such 

17 item or service; and 

18 ‘‘(F) meets any other requirement deter19 mined appropriate by the Secretary to ensure 

20 the accessibility and usability of information 

21 provided through such tool. 

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 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00076 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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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 January 1, 2026, each group health plan 

6 and health insurance issuer offering group or indi7 vidual health insurance coverage (other than a 

8 grandfathered health plan (as defined in section 

9 1251(e) of the Patient Protection and Affordable 

10 Care Act)) shall, for each month, not later than the 

11 tenth day of such month, make available to the pub12 lic the rate and payment information described in 

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

14 ‘‘(2) RATE AND PAYMENT INFORMATION DE15 SCRIBED.—For purposes of paragraph (1), the rate 

16 and payment information described in this para17 graph is, with respect to a group health plan or 

18 group or individual health insurance coverage, the 

19 following: 

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

21 (other than a drug) for which benefits are avail22 able under such plan or coverage, the in-net23 work rate (expressed as a dollar amount) in ef24 fect as of the date on which such information 

25 is made public with each provider that is a parVerDate Sep 11 2014 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00077 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 ticipating provider with respect to such item or 

2 service. 

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

4 by national drug code) for which benefits are 

5 available under such plan or coverage— 

6 ‘‘(i) the in-network rate (expressed as 

7 a dollar amount) in effect as of the first 

8 day of the month in which such informa9 tion is made public with each provider that 

10 is a participating provider with respect to 

11 such drug; and 

12 ‘‘(ii) the average amount paid by such 

13 plan (net of rebates, discounts, and price 

14 concessions) for such drug dispensed or 

15 administered during the 90-day period be16 ginning 180 days before such date of pub17 lication to each provider that was a partici18 pating provider with respect to such drug, 

19 broken down by each such provider, other 

20 than such an amount paid to a provider 

21 that, during such period, submitted fewer 

22 than 20 claims for such drug to such plan 

23 or coverage. 

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

25 for which benefits are available under such plan 


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1 or coverage, the amount billed, and the amount 

2 allowed by the plan, for each such item or serv3 ice furnished during the 90-day period specified 

4 in subparagraph (B) by a provider that was not 

5 a participating provider with respect to such 

6 item or service, broken down by each such pro7 vider. 

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

9 payment information required to be made available 

10 under this subsection shall be so made available in 

11 dollar amounts through separate machine-readable 

12 files (and any successor technology, such as applica13 tion program interface technology, determined ap14 propriate by the Secretary) corresponding to the in15 formation described in each of subparagraphs (A) 

16 through (C) of paragraph (2) that meet such re17 quirements as specified by the Secretary through 

18 subregulatory guidance. Such requirements shall en19 sure that such files are limited to an appropriate 

20 size, do not include disclosure of unnecessary dupli21 cative information contained in other files made 

22 available under this subsection, are made available 

23 in a widely-available format through a publicly-avail24 able website that allows for information contained in 

25 such files to be compared across group health plans 


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1 and group or individual health insurance coverage, 

2 and are accessible to individuals at no cost and with3 out the need to establish a user account or provide 

4 other credentials. 

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

6 plan and health insurance issuer offering group or 

7 individual health insurance coverage shall make 

8 available to the public instructions written in plain 

9 language explaining how individuals may search for 

10 information described in paragraph (2) in files sub11 mitted in accordance with paragraph (3). The Sec12 retary shall develop and publish through subregu13 latory guidance a template that such a plan may use 

14 in developing instructions for purposes of the pre15 ceding sentence. 

16 ‘‘(5) SUMMARY.—For each plan year beginning 

17 on or after January 1, 2026, each group health plan 

18 and health insurance issuer offering group or indi19 vidual health insurance coverage shall make public a 

20 data file, in a manner that ensures that such file 

21 may be easily downloaded and read by standard 

22 spreadsheet software and that meets such require23 ments as established by the Secretary, containing a 

24 summary of all rate and payment information made 

25 public by such plan or issuer with respect to such 


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1 plan or coverage during such plan year. Such file 

2 shall include the following: 

3 ‘‘(A) The mean, median, and interquartile 

4 range of the in-network rate, and the amount 

5 allowed for an item or service when not fur6 nished by a participating provider, in effect as 

7 of the first day of such plan year for each item 

8 or service (identified by payer identifier ap9 proved or used by the Centers for Medicare & 

10 Medicaid Services) for which benefits are avail11 able under the plan or coverage, broken down 

12 by the type of provider furnishing the item or 

13 service and by the geographic area in which 

14 such item or service is furnished. 

15 ‘‘(B) Trends in payment rates for such 

16 items and services over such plan year, includ17 ing an identification of instances in which such 

18 rates have increased, decreased, or remained 

19 the same. 

20 ‘‘(C) The name of such plan, a description 

21 of the type of network of participating providers 

22 used by such plan or coverage, and, in the case 

23 of a group health plan, a description of whether 

24 such plan is self-insured or fully-insured. 


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1 ‘‘(D) For each item or service which is 

2 paid as part of a bundled rate— 

3 ‘‘(i) a description of the formulae, 

4 pricing methodologies, or other information 

5 used to calculate the payment rate for such 

6 bundle; and 

7 ‘‘(ii) a list of the items and services 

8 included in such bundle. 

9 ‘‘(E) The percentage of items and services 

10 that are paid for on a fee-for-service basis and 

11 the percentage of items and services that are 

12 paid for as part of a bundled rate, capitated 

13 payment rate, or other alternative payment 

14 model. 

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

16 and health insurance issuer offering group or indi17 vidual health insurance coverage shall post, along 

18 with rate and payment information made public by 

19 such plan or issuer, an attestation that such infor20 mation is complete and accurate. 

21 ‘‘(c) ACCESSIBILITY.—A group health plan and a 

22 health insurance issuer offering group or individual health 

23 insurance coverage shall take reasonable steps (as speci24 fied by the Secretary) to ensure that information provided 

25 in response to a request described in subsection (a), and 


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1 rate and payment information made public under sub2 section (b), is provided in plain, easily understandable lan3 guage and that interpretation, translations, and assistive 

4 services are provided to those with limited English pro5 ficiency and those with disabilities. 

6 ‘‘(d) DEFINITIONS.—In this section: 

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

8 ‘participating provider’ means, with respect to an 

9 item or service and a group health plan or health in10 surance issuer offering group or individual health in11 surance coverage, a physician or other health care 

12 provider who is acting within the scope of practice 

13 of that provider’s license or certification under appli14 cable State law and who has a contractual relation15 ship with the plan or issuer, respectively, for fur16 nishing such item or service under the plan or cov17 erage, and includes facilities, respectively. 

18 ‘‘(2) PROVIDER.—The term ‘provider’ includes 

19 a health care facility. 

20 ‘‘(3) IN-NETWORK RATE.—The term ‘in-net21 work rate’ means, with respect to a group health 

22 plan or group or individual health insurance cov23 erage and an item or service furnished by a provider 

24 that is a participating provider with respect to such 

25 plan or coverage and item or service, the contracted 


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1 rate (reflected as a dollar amount) in effect between 

2 such plan or coverage and such provider for such 

3 item or service, regardless of whether such rate is 

4 calculated based on a set amount, a fee schedule, or 

5 an amount derived from another amount, or a for6 mula, or other method.’’. 

7 (3) ERISA.— 

8 (A) IN GENERAL.—Section 719 of the Em9 ployee Retirement Income Security Act of 1974 

10 (29 U.S.C. 1185h) is amended to read as fol11 lows: 

12 ‘‘SEC. 719. TRANSPARENCY IN COVERAGE. 

13 ‘‘(a) COST-SHARING TRANSPARENCY.— 

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

15 on or after January 1, 2026, a group health plan 

16 and a health insurance issuer offering group health 

17 insurance coverage shall permit a participant or ben18 eficiary to learn the amount of cost-sharing (includ19 ing deductibles, copayments, and coinsurance) under 

20 the participant or beneficiary’s plan or coverage that 

21 the participant or beneficiary would be responsible 

22 for paying with respect to the furnishing of a spe23 cific item or service by a provider in a timely man24 ner upon the request of the participant or bene25 ficiary. At a minimum, such information shall inVerDate Sep 11 2014 05:20 Sep 10, 2023 Jkt 039200 PO 00000 Frm 00084 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 clude the information specified in paragraph (2) and 

2 shall be made available to such participant or bene3 ficiary through a self-service tool that meets the re4 quirements of paragraph (3) or, at the option of 

5 such participant or beneficiary, through a paper dis6 closure or phone or other electronic disclosure (as 

7 selected by such participant or beneficiary and pro8 vided at no cost to such participant or beneficiary) 

9 that meets such requirements as the Secretary may 

10 specify. 

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

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

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

14 which benefits are available under a group health 

15 plan or group health insurance coverage furnished 

16 by a health care provider to a participant or bene17 ficiary of such plan or coverage, the following: 

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

19 provider with respect to such item or service, 

20 the in-network rate (as defined in subsection 

21 (c)) for such item or service. 

22 ‘‘(B) If such provider is not a participating 

23 provider with respect to such item or service, 

24 the maximum allowed amount or other dollar 

25 amount that such plan or coverage will recogVerDate Sep 11 2014 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00085 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 nize as payment for such item or service, along 

2 with a notice that such participant or bene3 ficiary may be liable for additional charges. 

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 allowed 

11 amount or other dollar amount described in 

12 such subparagraph). 

13 ‘‘(D) The amount the participant or bene14 ficiary has already accumulated with respect to 

15 any deductible or out of pocket maximum under 

16 the plan or coverage (broken down, in the case 

17 separate deductibles or maximums apply to sep18 arate participants and beneficiaries enrolled in 

19 the plan or coverage, by such separate 

20 deductibles or maximums, in addition to any 

21 cumulative deductible or maximum). 

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

23 frequency or volume limitations with respect to 

24 such item or service (excluding medical neces25 sity determinations), the amount that such parVerDate Sep 11 2014 05:20 Sep 10, 2023 Jkt 039200 PO 00000 Frm 00086 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 ticipant or beneficiary has accrued towards such 

2 limitation with respect to such item or service. 

3 ‘‘(F) Any prior authorization, concurrent 

4 review, step therapy, fail first, or similar re5 quirements applicable to coverage of such item 

6 or service under such plan or coverage. 

7 ‘‘(G) Any shared savings (such as any 

8 credit, payment, or other benefit provided by 

9 such plan or issuer) available to the participant 

10 or beneficiary with respect to such item or serv11 ice furnished by such provider known at the 

12 time such request is made. 

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

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

15 group health plan or health insurance issuer offering 

16 group health insurance coverage meets the require17 ments of this paragraph if such tool— 

18 ‘‘(A) is based on an internet website (or 

19 successor technology specified by the Sec20 retary); 

21 ‘‘(B) provides for real-time responses to re22 quests described in paragraph (1); 

23 ‘‘(C) is updated in a manner such that in24 formation provided through such tool is timely 

25 and accurate at the time such request is made; 


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

2 with respect to an item or service furnished 

3 by— 

4 ‘‘(i) a specific provider that is a par5 ticipating provider with respect to such 

6 item or service; 

7 ‘‘(ii) all providers that are partici8 pating providers with respect to such item 

9 or service; or 

10 ‘‘(iii) a provider in a relevant geo11 graphic region that is not described in 

12 clause (i) or (ii); 

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

14 made with respect to an item or service through 

15 use of the billing code for such item or service 

16 or through use of a descriptive term for such 

17 item or service; and 

18 ‘‘(F) meets any other requirement deter19 mined appropriate by the Secretary to ensure 

20 the accessibility and usability of information 

21 provided through such tool. 

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 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00088 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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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 January 1, 2026, each group health plan 

6 and health insurance issuer offering group health in7 surance coverage (other than a grandfathered health 

8 plan (as defined in section 1251(e) of the Patient 

9 Protection and Affordable Care Act)) shall, for each 

10 month, not later than the tenth day of such month, 

11 make available to the public the rate and payment 

12 information described in paragraph (2) in accord13 ance with paragraph (3). 

14 ‘‘(2) RATE AND PAYMENT INFORMATION DE15 SCRIBED.—For purposes of paragraph (1), the rate 

16 and payment information described in this para17 graph is, with respect to a group health plan or 

18 group health insurance coverage, the following: 

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

20 (other than a drug) for which benefits are avail21 able under such plan or coverage, the in-net22 work rate (expressed as a dollar amount) in ef23 fect as of the date on which such information 

24 is made public with each provider that is a parVerDate Sep 11 2014 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00089 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 ticipating provider with respect to such item or 

2 service. 

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

4 by national drug code) for which benefits are 

5 available under such plan or coverage— 

6 ‘‘(i) the in-network rate (expressed as 

7 a dollar amount) in effect as of the first 

8 day of the month in which such informa9 tion is made public with each provider that 

10 is a participating provider with respect to 

11 such drug; and 

12 ‘‘(ii) the average amount paid by such 

13 plan (net of rebates, discounts, and price 

14 concessions) for such drug dispensed or 

15 administered during the 90-day period be16 ginning 180 days before such date of pub17 lication to each provider that was a partici18 pating provider with respect to such drug, 

19 broken down by each such provider, other 

20 than such an amount paid to a provider 

21 that, during such period, submitted fewer 

22 than 20 claims for such drug to such plan 

23 or coverage. 

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

25 for which benefits are available under such plan 


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1 or coverage, the amount billed, and the amount 

2 allowed by the plan, for each such item or serv3 ice furnished during the 90-day period specified 

4 in subparagraph (B) by a provider that was not 

5 a participating provider with respect to such 

6 item or service, broken down by each such pro7 vider. 

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

9 payment information required to be made available 

10 under this subsection shall be so made available in 

11 dollar amounts through separate machine-readable 

12 files (and any successor technology, such as applica13 tion program interface technology, determined ap14 propriate by the Secretary) corresponding to the in15 formation described in each of subparagraphs (A) 

16 through (C) of paragraph (2) that meet such re17 quirements as specified by the Secretary through 

18 subregulatory guidance. Such requirements shall en19 sure that such files are limited to an appropriate 

20 size, do not include disclosure of unnecessary dupli21 cative information contained in other files made 

22 available under this subsection, are made available 

23 in a widely available format through a publicly avail24 able website that allows for information contained in 

25 such files to be compared across group health plans 


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1 and group or individual health insurance coverage, 

2 and are accessible to individuals at no cost and with3 out the need to establish a user account or provide 

4 other credentials. 

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

6 plan and health insurance issuer offering group 

7 health insurance coverage shall make available to the 

8 public instructions written in plain language explain9 ing how individuals may search for information de10 scribed in paragraph (2) in files submitted in ac11 cordance with paragraph (3). The Secretary shall 

12 develop and publish through subregulatory guidance 

13 a template that such a plan may use in developing 

14 instructions for purposes of the preceding sentence. 

15 ‘‘(5) SUMMARY.—For each plan year beginning 

16 on or after January 1, 2026, each group health plan 

17 and health insurance issuer offering group health in18 surance coverage shall make public a data file, in a 

19 manner that ensures that such file may be easily 

20 downloaded and read by standard spreadsheet soft21 ware and that meets such requirements as estab22 lished by the Secretary, containing a summary of all 

23 rate and payment information made public by such 

24 plan or issuer with respect to such plan or coverage 


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1 during such plan year. Such file shall include the fol2 lowing: 

3 ‘‘(A) The mean, median, and interquartile 

4 range of the in-network rate, and the amount 

5 allowed for an item or service when not fur6 nished by a participating provider, in effect as 

7 of the first day of such plan year for each item 

8 or service (identified by payer identifier ap9 proved or used by the Centers for Medicare & 

10 Medicaid Services) for which benefits are avail11 able under the plan or coverage, broken down 

12 by the type of provider furnishing the item or 

13 service and by the geographic area in which 

14 such item or service is furnished. 

15 ‘‘(B) Trends in payment rates for such 

16 items and services over such plan year, includ17 ing an identification of instances in which such 

18 rates have increased, decreased, or remained 

19 the same. 

20 ‘‘(C) The name of such plan, a description 

21 of the type of network of participating providers 

22 used by such plan or coverage, and, in the case 

23 of a group health plan, a description of whether 

24 such plan is self-insured or fully-insured. 


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1 ‘‘(D) For each item or service which is 

2 paid as part of a bundled rate— 

3 ‘‘(i) a description of the formulae, 

4 pricing methodologies, or other information 

5 used to calculate the payment rate for such 

6 bundle; and 

7 ‘‘(ii) a list of the items and services 

8 included in such bundle. 

9 ‘‘(E) The percentage of items and services 

10 that are paid for on a fee-for-service basis and 

11 the percentage of items and services that are 

12 paid for as part of a bundled rate, capitated 

13 payment rate, or other alternative payment 

14 model. 

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

16 and health insurance issuer offering group health in17 surance coverage shall post, along with rate and 

18 payment information made public by such plan or 

19 issuer, an attestation that such information is com20 plete and accurate. 

21 ‘‘(c) ACCESSIBILITY.—A group health plan and a 

22 health insurance issuer offering group health insurance 

23 coverage shall take reasonable steps (as specified by the 

24 Secretary) to ensure that information provided in response 

25 to a request described in subsection (a), and rate and payVerDate Sep 11 2014 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00094 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 ment information made public under subsection (b), is 

2 provided in plain, easily understandable language and that 

3 interpretation, translations, and assistive services are pro4 vided to those with limited English proficiency and those 

5 with disabilities. 

6 ‘‘(d) DEFINITIONS.—In this section: 

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

8 ‘participating provider’ means, with respect to an 

9 item or service and a group health plan or health in10 surance issuer offering group or individual health in11 surance coverage, a physician or other health care 

12 provider who is acting within the scope of practice 

13 of that provider’s license or certification under appli14 cable State law and who has a contractual relation15 ship with the plan or issuer, respectively, for fur16 nishing such item or service under the plan or cov17 erage, and includes facilities, respectively. 

18 ‘‘(2) PROVIDER.—The term ‘provider’ includes 

19 a health care facility. 

20 ‘‘(3) IN-NETWORK RATE.—The term ‘in-net21 work rate’ means, with respect to a group health 

22 plan or group health insurance coverage and an item 

23 or service furnished by a provider that is a partici24 pating provider with respect to such plan or cov25 erage and item or service, the contracted rate (reVerDate Sep 11 2014 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00095 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 flected as a dollar amount) in effect between such 

2 plan or coverage and such provider for such item or 

3 service, regardless of whether such rate is calculated 

4 based on a set amount, a fee schedule, or an amount 

5 derived from another amount, or a formula, or other 

6 method.’’. 

7 (B) CLERICAL AMENDMENT.—The table of 

8 contents in section 1 of the Employee Retire9 ment Income Security Act of 1974 is amended 

10 by striking the item relating to section 719 and 

11 inserting the following new item: 

‘‘Sec. 719. Transparency in coverage.’’. 

12 (b) APPLICATION PROGRAMMING INTERFACE RE13 PORT.—Not later than January 1, 2025, the Secretary of 

14 Health and Human Services shall, in consultation with the 

15 Office of the National Coordinator for Health Information 

16 Technology, Department of Labor, the Department of the 

17 Treasury, and stakeholders, submit to the House Commit18 tees on Education and the Workforce, Energy and Com19 merce, and Ways and Means, and the Senate Committees 

20 on Finance and Health, Education, Labor, and Pensions 

21 a report on the use of standards-based application pro22 gramming interfaces (in this subsection referred to as 

23 ‘‘APIs’’) to facilitate access to health care price trans24 parency information and the interoperability of other med25 ical information. Such report shall include an evaluation 


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1 of the capacity of the Department of Health and Human 

2 Services, the Department of Labor, and the Department 

3 of the Treasury to regulate and implement standards re4 lated to APIs and recommendations for improving such 

5 capacity. Such report shall include the following: 

6 (1) A description of current use, and proposed 

7 use, of APIs under Federal rules to facilitate inter8 operability, including information related to capacity 

9 constraints within the agencies, barriers to adoption, 

10 privacy and security, administrative burdens and ef11 ficiencies, care coordination, and levels of compli12 ance. 

13 (2) A description of the feasibility of agency 

14 participation in the development of APIs to enable 

15 application access to price transparency data under 

16 the amendments made by subsection (a). 

17 (3) A specification of the timeline for which 

18 such data standards can be required to make such 

19 data accessible via an API. 

20 (4) An analysis of the benefits and challenges 

21 of implementing standards-based APIs for price 

22 transparency data, including the ability for con23 sumers to access rate and payment information and 

24 the amount of cost-sharing (including deductibles, 

25 copayments, and coinsurance) under the consumer’s 


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1 plan through third-party internet-based tools and 

2 applications. 

3 (5) An analysis of the impact that APIs which 

4 provide real-time access to pricing and cost-sharing 

5 information may have in increasing the amount of 

6 services shoppable for individuals, such as by stand7 ardizing more health care spend via episode bundles. 

8 (6) An analysis of which health care items and 

9 services may be useful under API, such as those for 

10 which prices change with the greatest frequency. 

11 (7) An analysis of the cost of API standards 

12 implementation on issuers, employers, and other pri13 vate-sector entities. 

14 (8) An analysis of the ability of State regu15 lators to enforce API standards and the costs to the 

16 Federal Government and States to regulate and en17 force API standards. 

18 (9) An analysis of the interaction with API 

19 standards and Federal health information privacy 

20 standards. 

21 (c) PROVIDER TOOL REPORT.— 

22 (1) IN GENERAL.—Not later than 1 year after 

23 the date of the enactment of this Act, The Secretary 

24 of Health and Human Services, acting through the 

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1 icaid Services, shall, in consultation with stake2 holders, conduct a study and submit to the House 

3 Committees on Education and the Workforce, En4 ergy and Commerce, and Ways and Means, and the 

5 Senate Committees on Finance and Health, Edu6 cation, Labor, and Pensions a report on the useful7 ness and feasibility of the establishment of a pro8 vider tool by a group health plan, or a health insur9 ance issuer offering group and individual health in10 surance coverage, in facilitating the provision of in11 formation made available pursuant to the amend12 ments made by subsection (a). Such report shall in13 clude the following: 

14 (A) A description of the feasibility of es15 tablishing a requirement for the various types 

16 of plans and coverage to offer such a provider 

17 tool, including any challenges to establishing a 

18 provider tool using the same technology plat19 form as the self-service tool described in such 

20 amendments. 

21 (B) An evaluation on the usefulness of a 

22 provider tool to aid patient-decision making and 

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1 vider under other Federal requirements in place 

2 or under consideration. 

3 (C) An evaluation of whether the informa4 tion provided by such tool would be duplicative 

5 of the advanced explanation of benefits required 

6 under Federal law or any other existing require7 ment. 

8 (D) A description of the usability and ex9 pected utilization of such tool among providers, 

10 including among different provider types. 

11 (E) An analysis of the impact of a provider 

12 tool in value-based care arrangements. 

13 (F) An analysis on the potential impact of 

14 the provider tool on— 

15 (i) patients’ out-of-pocket spending; 

16 (ii) plan design, including impacts on 

17 cost-sharing requirements; 

18 (iii) care coordination and quality; 

19 (iv) plan premiums; 

20 (v) overall health care spending and 

21 utilization; and 

22 (vi) health care access in rural areas. 

23 (G) An analysis of the feasibility of a pro24 vider tool to include additional functionality to 

25 facilitate and improve the administration of the 


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1 requirements on providers to submit notifica2 tions to such plan or coverage under section 

3 2799B–6 of the Public Health Service Act and 

4 the requirements on such plan or coverage to 

5 provide an advanced explanation of benefits to 

6 individuals under section 2799A–1(f) of such 

7 Act. 

8 (H) An analysis of which health care items 

9 and services, would be most useful for patients 

10 utilizing a provider tool. 

11 (I) An analysis of rulemaking required to 

12 ensure such a tool complies with federal health 

13 information privacy standards. 

14 (J) An analysis of the burden and cost of 

15 the creation of a provider tool by plans and cov16 erage on providers, issuers, employers, and 

17 other private-sector entities. 

18 (K) An analysis of the ability of state reg19 ulators to enforce provider tool standards and 

20 the costs to the Department and states to regu21 late and enforce provider tool standards. 

22 (2) DEFINITION.—The term ‘‘provider tool’’ 

23 means a tool designed to facilitate the provision of 

24 information made available pursuant to the amend25 ments made by subsection (a) and established by a 


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1 group health plan or a health insurance issuer offer2 ing group and individual health insurance coverage 

3 that allows providers to access the information such 

4 plan or coverage must provide through the self-serv5 ice tool described in such amendments to an indi6 vidual with whom the provider is actively treating at 

7 the time of such request, upon the request of the 

8 provider, and with the consent of such individual. 

9 (d) REPORTS.— 

10 (1) COMPLIANCE.—Not later than January 1, 

11 2027, the Comptroller General of the United States 

12 shall submit to Congress a report containing— 

13 (A) an analysis of compliance with the 

14 amendments made by this section; 

15 (B) an analysis of enforcement of such 

16 amendments by the Secretaries of Health and 

17 Human Services, Labor, and the Treasury; 

18 (C) recommendations relating to improving 

19 such enforcement; and 

20 (D) recommendations relating to improving 

21 public disclosure, and public awareness, of in22 formation required to be made available by 

23 group health plans and health insurance issuers 

24 pursuant to such amendments. 


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1 (2) PRICES.—Not later than January 1, 2028, 

2 and biennially thereafter, the Secretaries of Health 

3 and Human Services, Labor, and the Treasury shall 

4 jointly submit to Congress a report containing an as5 sessment of differences in negotiated prices (and any 

6 trends in such prices) in the private market be7 tween— 

8 (A) rural and urban areas; 

9 (B) the individual, small group, and large 

10 group markets; 

11 (C) consolidated and nonconsolidated 

12 health care provider areas (as specified by the 

13 Secretary of Health and Human Services); 

14 (D) nonprofit and for-profit hospitals; 

15 (E) nonprofit and for-profit insurers; and 

16 (F) insurers serving local or regional areas 

17 and insurers serving multistate or national 

18 areas. 

19 (e) QUALITY REPORT.—Not later than 1 year after 

20 the date of enactment of this subsection, the Secretaries 

21 of Health and Human Services, Labor, and the Treasury 

22 shall jointly submit to Congress a report on the feasibility 

23 of including data relating to the quality of health care 

24 items and services with the price transparency information 

25 required to be made available under the amendments 


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1 made by subsection (a). Such report shall include rec2 ommendations for legislative and regulatory actions to 

3 identify appropriate metrics for assessing and comparing 

4 quality of care. 

5 (f) CONTINUED APPLICABILITY OF RULES FOR PRE6 VIOUS YEARS.—Nothing in the amendments made by sub7 section (a) may be construed as affecting the applicability 

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

9 by the Department of the Treasury, the Department of 

10 Labor, and the Department of Health and Human Serv11 ices on November 12, 2020 (85 Fed. Reg. 72158), for any 

12 plan year beginning before January 1, 2026. 

13 SEC. 106. PHARMACY BENEFITS PRICE TRANSPARENCY. 

14 (a) PHSA.—Title XXVII of the Public Health Serv15 ice Act (42 U.S.C. 300gg et seq.) is amended— 

16 (1) in part D (42 U.S.C. 300gg–111 et seq.), 

17 by adding at the end the following new section: 

18 ‘‘SEC. 2799A–11. OVERSIGHT OF PHARMACY BENEFITS MAN19 AGER SERVICES. 

20 ‘‘(a) IN GENERAL.—For plan years beginning on or 

21 after the date that is 2 years after the date of enactment 

22 of this section, a group health plan or a health insurance 

23 issuer offering group health insurance coverage, or an en24 tity or subsidiary providing pharmacy benefits manage25 ment services on behalf of such a plan or issuer, shall not 


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1 enter into a contract with a drug manufacturer, dis2 tributor, wholesaler, subcontractor, rebate aggregator, or 

3 any other third party that limits (or delays beyond the 

4 applicable reporting period described in subsection (b)(1)) 

5 the disclosure of information to plan sponsors in such a 

6 manner that prevents such plan, issuer, or entity from 

7 making the reports described in subsection (b). 

8 ‘‘(b) REPORTS.— 

9 ‘‘(1) IN GENERAL.—With respect to plan years 

10 beginning on or after the date that is 2 years after 

11 the date of enactment of this section, not less fre12 quently than every 6 months (or at the request of 

13 a plan sponsor, not less frequently than quarterly, 

14 but under the same conditions, terms, and cost of 

15 the semiannual report under this subsection), a 

16 group health plan or health insurance issuer offering 

17 group health insurance coverage, or an entity pro18 viding pharmacy benefits management services on 

19 behalf of such a plan or issuer, shall submit to the 

20 plan sponsor (as defined in section 3(16)(B) of the 

21 Employee Retirement Income Security Act of 1974) 

22 of such plan or coverage a report in accordance with 

23 this section. Each such report shall be made avail24 able to such plan sponsor in a machine-readable forVerDate Sep 11 2014 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00105 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 mat and shall include the information described in 

2 paragraph (2). 

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

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

5 paragraph is, with respect to drugs covered by a 

6 group health plan or health insurance issuer offering 

7 group health insurance coverage during each report8 ing period— 

9 ‘‘(A) a list of drugs for which a claim was 

10 filed and, with respect to each such drug on 

11 such list— 

12 ‘‘(i) the brand name, chemical entity, 

13 and National Drug Code; 

14 ‘‘(ii) the type of dispensing channel 

15 used to furnish such drug, including retail, 

16 mail order, or specialty pharmacy; 

17 ‘‘(iii) with respect to each drug dis18 pensed under each type of dispensing chan19 nel (including retail, mail order, or spe20 cialty pharmacy)— 

21 ‘‘(I) whether such drug is a 

22 brand name drug or a generic drug, 

23 and— 

24 ‘‘(aa) in the case of a brand 

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1 tion cost, listed as cost per days 

2 supply and cost per dosage unit, 

3 on the date such drug was dis4 pensed; and 

5 ‘‘(bb) in the case of a ge6 neric drug, the average wholesale 

7 price, listed as cost per days sup8 ply and cost per dosage unit, on 

9 the date such drug was dis10 pensed; and 

11 ‘‘(II) the total number of— 

12 ‘‘(aa) prescription claims 

13 (including original prescriptions 

14 and refills); 

15 ‘‘(bb) participants, bene16 ficiaries, and enrollees for whom 

17 a claim for such drug was filed; 

18 ‘‘(cc) dosage units per fill of 

19 such drug; and 

20 ‘‘(dd) days supply of such 

21 drug per fill; 

22 ‘‘(iv) the net price per course of treat23 ment or single fill, such as a 30-day supply 

24 or 90-day supply to the plan or coverage 


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1 after manufacturer rebates, fees, and other 

2 remuneration or adjustments; 

3 ‘‘(v) the total amount of out-of-pocket 

4 spending by participants, beneficiaries, and 

5 enrollees on such drug, including spending 

6 through copayments, coinsurance, and 

7 deductibles; 

8 ‘‘(vi) the total net spending by the 

9 plan or coverage; 

10 ‘‘(vii) total amount received, or ex11 pected to be received, by the plan or cov12 erage from any entity in drug manufac13 turer rebates, fees, alternative discounts, 

14 and all other remuneration received from 

15 an entity or any third party (including 

16 group purchasing organizations) other 

17 than the plan sponsor; 

18 ‘‘(viii) the total amount received, or 

19 expected to be received by the plan or 

20 issuer, from drug manufacturers in re21 bates, fees, alternative discounts, or other 

22 remuneration— 

23 ‘‘(I) that has been paid, or is to 

24 be paid, by drug manufacturers for 


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1 claims incurred during the reporting 

2 period; and 

3 ‘‘(II) that is related to utilization 

4 rebates for such drug; and 

5 ‘‘(ix) to the extent feasible, informa6 tion on the total amount of remuneration, 

7 including copayment assistance dollars 

8 paid, copayment cards applied, or other 

9 discounts provided by each drug manufac10 turer (or entity administering copay assist11 ance on behalf of such drug manufacturer) 

12 to the participants, beneficiaries, and en13 rollees enrolled in such plan or coverage; 

14 ‘‘(B) for each category or class of drugs 

15 for which a claim was filed, a breakdown of the 

16 total gross spending on drugs in such category 

17 or class before rebates, price concessions, alter18 native discounts, or other remuneration from 

19 drug manufacturers, and the net spending after 

20 such rebates, price concessions, alternative dis21 counts, or other remuneration from drug manu22 facturers, including— 

23 ‘‘(i) the number of participants, bene24 ficiaries, and enrollees who filled a pre25 scription for a drug in such category or 


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1 class, including the National Drug Code 

2 for each such drug; 

3 ‘‘(ii) if applicable, a description of the 

4 formulary tiers and utilization mechanisms 

5 (such as prior authorization or step ther6 apy) employed for drugs in that category 

7 or class; and 

8 ‘‘(iii) the total out-of-pocket spending 

9 under the plan or coverage by participants, 

10 beneficiaries, and enrollees, including 

11 spending through copayments, coinsurance, 

12 and deductibles; 

13 ‘‘(C) in the case of a drug for which gross 

14 spending by such plan, coverage, or entity ex15 ceeded $10,000 during the reporting period— 

16 ‘‘(i) a list of all other drugs in the 

17 same therapeutic category or class; and 

18 ‘‘(ii) the rationale for the formulary 

19 placement of such drug in that therapeutic 

20 category or class, if applicable; 

21 ‘‘(D) amounts paid directly or indirectly in 

22 rebates, fees, or any other type of compensation 

23 (as defined in section 408(b)(2)(B)(ii)(dd)(AA) 

24 of the Employee Retirement Income Security 

25 Act) to brokers, consultants, advisors, or any 


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1 other individual or firm, for the referral of the 

2 group health plan’s or health insurance issuer’s 

3 business to an entity providing pharmacy bene4 fits management services, including the identity 

5 of the recipient of such amounts; 

6 ‘‘(E) an explanation of any benefit design 

7 parameters that encourage or require partici8 pants, beneficiaries, and enrollees in such plan 

9 or coverage to fill prescriptions at mail order, 

10 specialty, or retail pharmacies that are affili11 ated with or under common ownership with the 

12 entity providing pharmacy benefit management 

13 services under such plan or coverage, including 

14 mandatory mail and specialty home delivery 

15 programs, retail and mail auto-refill programs, 

16 and cost-sharing assistance incentives directly 

17 or indirectly funded by such entity; and 

18 ‘‘(F) in the case of a plan or coverage (or 

19 an entity providing pharmacy benefits manage20 ment services on behalf of such plan or cov21 erage) that has an affiliated pharmacy or phar22 macy under common ownership— 

23 ‘‘(i) the percentage of total prescrip24 tions dispensed by such pharmacies to in25 dividuals enrolled in such plan or coverage; 


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1 ‘‘(ii) a list of all drugs dispensed by 

2 such pharmacies to individuals enrolled in 

3 such plan or coverage, and, with respect to 

4 each drug dispensed— 

5 ‘‘(I) the amount charged, per 

6 dosage unit, per 30-day supply, or per 

7 90-day supply (as applicable) to the 

8 plan or issuer, and to participants, 

9 beneficiaries, and enrollees enrolled in 

10 such plan or coverage; 

11 ‘‘(II) the median amount charged 

12 to such plan or issuer, and the inter13 quartile range of the costs, per dosage 

14 unit, per 30-day supply, and per 90- 

15 day supply, including amounts paid by 

16 the participants, beneficiaries, and en17 rollees, when the same drug is dis18 pensed by other pharmacies that are 

19 not affiliated with or under common 

20 ownership with the entity and that are 

21 included in the pharmacy network of 

22 such plan or coverage; 

23 ‘‘(III) the lowest cost per dosage 

24 unit, per 30-day supply and per 90- 

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1 cluding amounts charged to the plan 

2 and participants, beneficiaries, and 

3 enrollees, that is available from any 

4 pharmacy included in the network of 

5 such plan or coverage; and 

6 ‘‘(IV) the net acquisition cost per 

7 dosage unit, per 30-day supply, and 

8 per 90-day supply, if such drug is 

9 subject to a maximum price discount. 

10 ‘‘(3) PRIVACY REQUIREMENTS.—Health insur11 ance issuers offering group health insurance cov12 erage and entities providing pharmacy benefits man13 agement services on behalf of a group health plan 

14 shall provide information under paragraph (1) in a 

15 manner consistent with the privacy, security, and 

16 breach notification regulations promulgated under 

17 section 13402(a) of the Health Information Tech18 nology for Clinical Health Act, and shall restrict the 

19 use and disclosure of such information according to 

20 such privacy regulations. 

21 ‘‘(4) DISCLOSURE AND REDISCLOSURE.— 

22 ‘‘(A) LIMITATION TO BUSINESS ASSOCI23 ATES.—A plan sponsor receiving a report under 

24 paragraph (1) may disclose such information 

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1 ceived, the group health plan for which the re2 port pertains, or to that entity’s business asso3 ciates as defined in section 160.103 of title 45, 

4 Code of Federal Regulations (or successor regu5 lations) or as permitted by the HIPAA Privacy 

6 Rule (45 CFR parts 160 and 164, subparts A 

7 and E). 

8 ‘‘(B) CLARIFICATION REGARDING PUBLIC

9 DISCLOSURE OF INFORMATION.—Nothing in 

10 this section shall prevent a group health plan or 

11 health insurance issuer offering group health 

12 insurance coverage, or an entity providing phar13 macy benefits management services on behalf of 

14 such a plan or coverage, from placing reason15 able restrictions on the public disclosure of the 

16 information contained in a report described in 

17 paragraph (1), except that such plan, issuer, or 

18 entity may not restrict disclosure of such report 

19 to the Department of Health and Human Serv20 ices, the Department of Labor, the Department 

21 of the Treasury, or the Comptroller General of 

22 the United States. 

23 ‘‘(C) LIMITED FORM OF REPORT.—The 

24 Secretary shall define through rulemaking a 

25 limited form of the report under paragraph (1) 


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1 required of plan sponsors who are drug manu2 facturers, drug wholesalers, or other direct par3 ticipants in the drug supply chain, in order to 

4 prevent anti-competitive behavior. 

5 ‘‘(5) REPORT TO GAO.—A group health plan or 

6 health insurance issuer offering group health insur7 ance coverage, or an entity providing pharmacy ben8 efits management services on behalf of such plan or 

9 coverage, shall submit to the Comptroller General of 

10 the United States each of the first 4 reports sub11 mitted to a plan sponsor under paragraph (1) and 

12 other such reports as requested, in accordance with 

13 the privacy requirements under paragraph (3), the 

14 disclosure and redisclosure standards under para15 graph (4), the standards specified pursuant to para16 graph (6), and such other information that the 

17 Comptroller General determines necessary to carry 

18 out the study under section 106(d) of the Lower 

19 Costs, More Transparency Act. 

20 ‘‘(6) STANDARD FORMAT.—Not later than 1 

21 year after the date of enactment of this section, the 

22 Secretary shall specify through rulemaking stand23 ards for group health plans, health insurance issuers 

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1 ices on behalf of such plans or coverage, required to 

2 submit reports under paragraph (1) to submit such 

3 reports in a standard format. 

4 ‘‘(c) ENFORCEMENT.— 

5 ‘‘(1) IN GENERAL.—The Secretary shall enforce 

6 this section. 

7 ‘‘(2) FAILURE TO PROVIDE TIMELY INFORMA8 TION.—A health insurance issuer or an entity pro9 viding pharmacy benefits management services on 

10 behalf of such plan or coverage that violates sub-sec11 tion (a) or fails to provide the information required 

12 under subsection (b) shall be subject to a civil mone13 tary penalty in the amount of $10,000 for each day 

14 during which such violation continues or such infor15 mation is not disclosed or reported. 

16 ‘‘(3) FALSE INFORMATION.—A health insurance 

17 issuer or an entity providing pharmacy benefits 

18 management services on behalf of such a plan or 

19 coverage that knowingly provides false information 

20 under this section shall be subject to a civil money 

21 penalty in an amount not to exceed $100,000 for 

22 each item of false information. Such civil money 

23 penalty shall be in addition to other penalties as 

24 may be prescribed by law. 


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1 ‘‘(4) PROCEDURE.—The provisions of section 

2 1128A of the Social Security Act, other than sub3 sections (a) and (b) and the first sentence of sub4 section (c)(1) of such section shall apply to civil 

5 monetary penalties under this subsection in the 

6 same manner as such provisions apply to a penalty 

7 or proceeding under such section. 

8 ‘‘(5) WAIVERS.—The Secretary may waive pen9 alties under paragraph (2), or extend the period of 

10 time for compliance with a requirement of this sec11 tion, for an entity in violation of this section that 

12 has made a good-faith effort to comply with the re13 quirements in this section. 

14 ‘‘(d) RULE OF CONSTRUCTION.—Nothing in this sec15 tion shall be construed to permit a group health plan, 

16 health insurance issuer, or entity providing pharmacy ben17 efits management services on behalf of such plan or cov18 erage, to restrict disclosure to, or otherwise limit the ac19 cess of, the Department of Health and Human Services 

20 to a report described in subsection (b)(1) or information 

21 related to compliance with subsection (a) or (b) by entities 

22 subject to such subsection. 

23 ‘‘(e) DEFINITION.—In this section, the term ‘whole24 sale acquisition cost’ has the meaning given such term in 

25 section 1847A(c)(6)(B) of the Social Security Act.’’; and 


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1 (2) in section 2723 (42 U.S.C. 300gg–22)— 

2 (A) in subsection (a)— 

3 (i) in paragraph (1), by inserting 

4 ‘‘(other than subsections (a) and (b) of 

5 section 2799A–11)’’ after ‘‘part D’’; and 

6 (ii) in paragraph (2), by inserting 

7 ‘‘(other than subsections (a) and (b) of 

8 section 2799A–11)’’ after ‘‘part D’’; and 

9 (B) in subsection (b)— 

10 (i) in paragraph (1), by inserting 

11 ‘‘(other than subsections (a) and (b) of 

12 section 2799A–11)’’ after ‘‘part D’’; 

13 (ii) in paragraph (2)(A), by inserting 

14 ‘‘(other than subsections (a) and (b) of 

15 section 2799A–11)’’ after ‘‘part D’’; and 

16 (iii) in paragraph (2)(C)(ii), by insert17 ing ‘‘(other than subsections (a) and (b) of 

18 section 2799A–11)’’ after ‘‘part D’’. 

19 (b) ERISA.— 

20 (1) IN GENERAL.—Subtitle B of title I of the 

21 Employee Retirement Income Security Act of 1974 

22 (29 U.S.C. 1021 et seq.) is amended— 

23 (A) in subpart B of part 7 (29 U.S.C. 

24 1185 et seq.), by adding at the end the fol25 lowing: 


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1 ‘‘SEC. 726. OVERSIGHT OF PHARMACY BENEFIT MANAGER 

2 SERVICES. 

3 ‘‘(a) IN GENERAL.—For plan years beginning on or 

4 after the date that is 2 years after the date of enactment 

5 of this section, a group health plan or a health insurance 

6 issuer offering group health insurance coverage, or an en7 tity or subsidiary providing pharmacy benefits manage8 ment services on behalf of such a plan or issuer, shall not 

9 enter into a contract with a drug manufacturer, dis10 tributor, wholesaler, subcontractor, rebate aggregator, or 

11 any other third party that limits (or delays beyond the 

12 applicable reporting period described in subsection (b)(1)) 

13 the disclosure of information to plan sponsors in such a 

14 manner that prevents such plan, issuer, or entity from 

15 making the reports described in subsection (b). 

16 ‘‘(b) REPORTS.— 

17 ‘‘(1) IN GENERAL.—With respect to plan years 

18 beginning on or after the date that is 2 years after 

19 the date of enactment of this section, not less fre20 quently than every 6 months (or at the request of 

21 a plan sponsor, not less frequently than quarterly, 

22 but under the same conditions, terms, and cost of 

23 the semiannual report under this subsection), a 

24 group health plan or health insurance issuer offering 

25 group health insurance coverage, or an entity pro26 viding pharmacy benefits management services on 


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1 behalf of such a plan or issuer, shall submit to the 

2 plan sponsor (as defined in section 3(16)(B)) of 

3 such plan or coverage a report in accordance with 

4 this section. Each such report shall be made avail5 able to such plan sponsor in a machine-readable for6 mat and shall include the information described in 

7 paragraph (2). 

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

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

10 paragraph is, with respect to drugs covered by a 

11 group health plan or health insurance issuer offering 

12 group health insurance coverage during each report13 ing period— 

14 ‘‘(A) a list of drugs for which a claim was 

15 filed and, with respect to each such drug on 

16 such list— 

17 ‘‘(i) the brand name, chemical entity, 

18 and National Drug Code; 

19 ‘‘(ii) the type of dispensing channel 

20 used to furnish such drug, including retail, 

21 mail order, or specialty pharmacy; 

22 ‘‘(iii) with respect to each drug dis23 pensed under each type of dispensing chan24 nel (including retail, mail order, or spe25 cialty pharmacy)— 


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1 ‘‘(I) whether such drug is a 

2 brand name drug or a generic drug, 

3 and— 

4 ‘‘(aa) in the case of a brand 

5 name drug, the wholesale acquisi6 tion cost, listed as cost per days 

7 supply and cost per dosage unit, 

8 on the date such drug was dis9 pensed; and 

10 ‘‘(bb) in the case of a ge11 neric drug, the average wholesale 

12 price, listed as cost per days sup13 ply and cost per dosage unit, on 

14 the date such drug was dis15 pensed; and 

16 ‘‘(II) the total number of— 

17 ‘‘(aa) prescription claims 

18 (including original prescriptions 

19 and refills); 

20 ‘‘(bb) participants, bene21 ficiaries, and enrollees for whom 

22 a claim for such drug was filed; 

23 ‘‘(cc) dosage units per fill of 

24 such drug; and 


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1 ‘‘(dd) days supply of such 

2 drug per fill; 

3 ‘‘(iv) the net price per course of treat4 ment or single fill, such as a 30-day supply 

5 or 90-day supply to the plan or coverage 

6 after manufacturer rebates, fees, and other 

7 remuneration or adjustments; 

8 ‘‘(v) the total amount of out-of-pocket 

9 spending by participants, beneficiaries, and 

10 enrollees on such drug, including spending 

11 through copayments, coinsurance, and 

12 deductibles; 

13 ‘‘(vi) the total net spending by the 

14 plan or coverage; 

15 ‘‘(vii) total amount received, or ex16 pected to be received, by the plan or cov17 erage from any entity in drug manufac18 turer rebates, fees, alternative discounts, 

19 and all other remuneration received from 

20 an entity or any third party (including 

21 group purchasing organizations) other 

22 than the plan sponsor; 

23 ‘‘(viii) the total amount received, or 

24 expected to be received by the plan or 

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1 bates, fees, alternative discounts, or other 

2 remuneration— 

3 ‘‘(I) that has been paid, or is to 

4 be paid, by drug manufacturers for 

5 claims incurred during the reporting 

6 period; and 

7 ‘‘(II) that is related to utilization 

8 rebates for such drug; and 

9 ‘‘(ix) to the extent feasible, informa10 tion on the total amount of remuneration, 

11 including copayment assistance dollars 

12 paid, copayment cards applied, or other 

13 discounts provided by each drug manufac14 turer (or entity administering copay assist15 ance on behalf of such drug manufacturer) 

16 to the participants, beneficiaries, and en17 rollees enrolled in such plan or coverage; 

18 ‘‘(B) for each category or class of drugs 

19 for which a claim was filed, a breakdown of the 

20 total gross spending on drugs in such category 

21 or class before rebates, price concessions, alter22 native discounts, or other remuneration from 

23 drug manufacturers, and the net spending after 

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1 counts, or other remuneration from drug manu2 facturers, including— 

3 ‘‘(i) the number of participants, bene4 ficiaries, and enrollees who filled a pre5 scription for a drug in such category or 

6 class, including the National Drug Code 

7 for each such drug; 

8 ‘‘(ii) if applicable, a description of the 

9 formulary tiers and utilization mechanisms 

10 (such as prior authorization or step ther11 apy) employed for drugs in that category 

12 or class; and 

13 ‘‘(iii) the total out-of-pocket spending 

14 under the plan or coverage by participants, 

15 beneficiaries, and enrollees, including 

16 spending through copayments, coinsurance, 

17 and deductibles; 

18 ‘‘(C) in the case of a drug for which gross 

19 spending by such plan, coverage, or entity ex20 ceeded $10,000 during the reporting period— 

21 ‘‘(i) a list of all other drugs in the 

22 same therapeutic category or class; and 

23 ‘‘(ii) the rationale for the formulary 

24 placement of such drug in that therapeutic 

25 category or class, if applicable; 


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1 ‘‘(D) amounts paid directly or indirectly in 

2 rebates, fees, or any other type of compensation 

3 (as defined in section 408(b)(2)(B)(ii)(dd)(AA)) 

4 to brokers, consultants, advisors, or any other 

5 individual or firm, for the referral of the group 

6 health plan’s or health insurance issuer’s busi7 ness to an entity providing pharmacy benefits 

8 management services, including the identity of 

9 the recipient of such amounts; 

10 ‘‘(E) an explanation of any benefit design 

11 parameters that encourage or require partici12 pants, beneficiaries, and enrollees in such plan 

13 or coverage to fill prescriptions at mail order, 

14 specialty, or retail pharmacies that are affili15 ated with or under common ownership with the 

16 entity providing pharmacy benefit management 

17 services under such plan or coverage, including 

18 mandatory mail and specialty home delivery 

19 programs, retail and mail auto-refill programs, 

20 and cost-sharing assistance incentives directly 

21 or indirectly funded by such entity; and 

22 ‘‘(F) in the case of a plan or coverage (or 

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1 erage) that has an affiliated pharmacy or phar2 macy under common ownership— 

3 ‘‘(i) the percentage of total prescrip4 tions dispensed by such pharmacies to in5 dividuals enrolled in such plan or coverage; 

6 ‘‘(ii) a list of all drugs dispensed by 

7 such pharmacies to individuals enrolled in 

8 such plan or coverage, and, with respect to 

9 each drug dispensed— 

10 ‘‘(I) the amount charged, per 

11 dosage unit, per 30-day supply, or per 

12 90-day supply (as applicable) to the 

13 plan or issuer, and to participants, 

14 beneficiaries, and enrollees enrolled in 

15 such plan or coverage; 

16 ‘‘(II) the median amount charged 

17 to such plan or issuer, and the inter18 quartile range of the costs, per dosage 

19 unit, per 30-day supply, and per 90- 

20 day supply, including amounts paid by 

21 the participants, beneficiaries, and en22 rollees, when the same drug is dis23 pensed by other pharmacies that are 

24 not affiliated with or under common 

25 ownership with the entity and that are 


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1 included in the pharmacy network of 

2 such plan or coverage; 

3 ‘‘(III) the lowest cost per dosage 

4 unit, per 30-day supply and per 90- 

5 day supply, for each such drug, in6 cluding amounts charged to the plan 

7 and participants, beneficiaries, and 

8 enrollees, that is available from any 

9 pharmacy included in the network of 

10 such plan or coverage; and 

11 ‘‘(IV) the net acquisition cost per 

12 dosage unit, per 30-day supply, and 

13 per 90-day supply, if such drug is 

14 subject to a maximum price discount. 

15 ‘‘(3) PRIVACY REQUIREMENTS.—Health insur16 ance issuers offering group health insurance cov17 erage and entities providing pharmacy benefits man18 agement services on behalf of a group health plan 

19 shall provide information under paragraph (1) in a 

20 manner consistent with the privacy, security, and 

21 breach notification regulations promulgated under 

22 section 13402(a) of the Health Information Tech23 nology for Clinical Health Act, and shall restrict the 

24 use and disclosure of such information according to 

25 such privacy regulations. 


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1 ‘‘(4) DISCLOSURE AND REDISCLOSURE.— 

2 ‘‘(A) LIMITATION TO BUSINESS ASSOCI3 ATES.—A plan sponsor receiving a report under 

4 paragraph (1) may disclose such information 

5 only to the entity from which the report was re6 ceived, the group health plan for which the re7 port pertains, or to that entity’s business asso8 ciates as defined in section 160.103 of title 45, 

9 Code of Federal Regulations (or successor regu10 lations) or as permitted by the HIPAA Privacy 

11 Rule (45 CFR parts 160 and 164, subparts A 

12 and E). 

13 ‘‘(B) CLARIFICATION REGARDING PUBLIC

14 DISCLOSURE OF INFORMATION.—Nothing in 

15 this section shall prevent a group health plan or 

16 health insurance issuer offering group health 

17 insurance coverage, or an entity providing phar18 macy benefits management services on behalf of 

19 such a plan or coverage, from placing reason20 able restrictions on the public disclosure of the 

21 information contained in a report described in 

22 paragraph (1), except that such plan, issuer, or 

23 entity may not restrict disclosure of such report 

24 to the Department of Health and Human Serv25 ices, the Department of Labor, the Department 


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1 of the Treasury, or the Comptroller General of 

2 the United States. 

3 ‘‘(C) LIMITED FORM OF REPORT.—The 

4 Secretary shall define through rulemaking a 

5 limited form of the report under paragraph (1) 

6 required of plan sponsors who are drug manu7 facturers, drug wholesalers, or other direct par8 ticipants in the drug supply chain, in order to 

9 prevent anti-competitive behavior. 

10 ‘‘(5) REPORT TO GAO.—A group health plan or 

11 health insurance issuer offering group health insur12 ance coverage, or an entity providing pharmacy ben13 efits management services on behalf of such plan or 

14 coverage, shall submit to the Comptroller General of 

15 the United States each of the first 4 reports sub16 mitted to a plan sponsor under paragraph (1) and 

17 other such reports as requested, in accordance with 

18 the privacy requirements under paragraph (3), the 

19 disclosure and redisclosure standards under para20 graph (4), the standards specified pursuant to para21 graph (6), and such other information that the 

22 Comptroller General determines necessary to carry 

23 out the study under section 106(d) of the Lower 

24 Costs, More Transparency Act. 


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1 ‘‘(6) STANDARD FORMAT.—Not later than 1 

2 year after the date of enactment of this section, the 

3 Secretary shall specify through rulemaking stand4 ards for group health plans, health insurance issuers 

5 offering group health insurance coverage, and enti6 ties providing pharmacy benefits management serv7 ices on behalf of such plans or coverage, required to 

8 submit reports under paragraph (1) to submit such 

9 reports in a standard format. 

10 ‘‘(c) RULE OF CONSTRUCTION.—Nothing in this sec11 tion shall be construed to permit a group health plan, 

12 health insurance issuer, or entity providing pharmacy ben13 efits management services on behalf of such plan or cov14 erage, to restrict disclosure to, or otherwise limit the ac15 cess of, the Secretary of Labor to a report described in 

16 subsection (b)(1) or information related to compliance 

17 with subsection (a) or (b) by entities subject to such sub18 section. 

19 ‘‘(d) DEFINITION.—In this section, the term ‘whole20 sale acquisition cost’ has the meaning given such term in 

21 section 1847A(c)(6)(B) of the Social Security Act.’’. 

22 (B) in section 502 (29 U.S.C. 1132)— 

23 (i) in subsection (b)(3), by striking 

24 ‘‘under subsection (c)(9))’’ and inserting 


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1 ‘‘under paragraphs (9) and (13) of sub2 section (c))’’; and 

3 (ii) in subsection (c), by adding at the 

4 end the following new paragraph: 

5 ‘‘(13) SECRETARIAL ENFORCEMENT AUTHORITY

6 RELATING TO OVERSIGHT OF PHARMACY BENEFITS

7 MANAGER SERVICES.— 

8 ‘‘(A) FAILURE TO PROVIDE TIMELY INFOR9 MATION.—The Secretary may impose a penalty 

10 against any health insurance issuer or entity 

11 providing pharmacy benefits management serv12 ices that violates section 726(a) or fails to pro13 vide information required under section 726(b) 

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

15 which such violation continues or such informa16 tion is not disclosed or reported. 

17 ‘‘(B) FALSE INFORMATION.—The Sec18 retary may impose a penalty against a health 

19 insurance issuer or entity providing pharmacy 

20 benefits management services that knowingly 

21 provides false information under section 726 in 

22 an amount not to exceed $100,000 for each 

23 item of false information. Such penalty shall be 

24 in addition to other penalties as may be pre25 scribed by law. 


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1 ‘‘(C) WAIVERS.—The Secretary may waive 

2 penalties under subparagraph (A), or extend 

3 the period of time for compliance with a re4 quirement of section 726, for an entity in viola5 tion of such section that has made a good-faith 

6 effort to comply with such section.’’. 

7 (2) CLERICAL AMENDMENT.—The table of con8 tents in section 1 of the Employee Retirement In9 come Security Act of 1974 (29 U.S.C. 1001 et seq.) 

10 is amended by inserting after the item relating to 

11 section 725 the following new item: 

‘‘Sec. 726. Oversight of pharmacy benefits manager services.’’. 

12 (c) IRC.— 

13 (1) IN GENERAL.—Subchapter B of chapter 

14 100 of the Internal Revenue Code of 1986 is amend15 ed by adding at the end the following: 

16 ‘‘SEC. 9826. OVERSIGHT OF PHARMACY BENEFIT MANAGER 

17 SERVICES. 

18 ‘‘(a) IN GENERAL.—For plan years beginning on or 

19 after the date that is 2 years after the date of enactment 

20 of this section, a group health plan, or an entity or sub21 sidiary providing pharmacy benefits management services 

22 on behalf of such a plan, shall not enter into a contract 

23 with a drug manufacturer, distributor, wholesaler, subcon24 tractor, rebate aggregator, or any other third party that 

25 limits (or delays beyond the applicable reporting period deVerDate Sep 11 2014 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00132 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 scribed in subsection (b)(1)) the disclosure of information 

2 to plan sponsors in such a manner that prevents such plan 

3 or entity from making the reports described in subsection 

4 (b). 

5 ‘‘(b) REPORTS.— 

6 ‘‘(1) IN GENERAL.—With respect to plan years 

7 beginning on or after the date that is 2 years after 

8 the date of enactment of this section, not less fre9 quently than every 6 months (or at the request of 

10 a plan sponsor, not less frequently than quarterly, 

11 but under the same conditions, terms, and cost of 

12 the semiannual report under this subsection), a 

13 group health plan, or an entity providing pharmacy 

14 benefits management services on behalf of such a 

15 plan, shall submit to the plan sponsor (as defined in 

16 section 3(16)(B) of the Employee Retirement In17 come Security Act of 1974) of such plan a report in 

18 accordance with this section. Each such report shall 

19 be made available to such plan sponsor in a ma20 chine-readable format and shall include the informa21 tion described in paragraph (2). 

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

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

24 paragraph is, with respect to drugs covered by a 

25 group health plan during each reporting period— 


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1 ‘‘(A) a list of drugs for which a claim was 

2 filed and, with respect to each such drug on 

3 such list— 

4 ‘‘(i) the brand name, chemical entity, 

5 and National Drug Code; 

6 ‘‘(ii) the type of dispensing channel 

7 used to furnish such drug, including retail, 

8 mail order, or specialty pharmacy; 

9 ‘‘(iii) with respect to each drug dis10 pensed under each type of dispensing chan11 nel (including retail, mail order, or spe12 cialty pharmacy)— 

13 ‘‘(I) whether such drug is a 

14 brand name drug or a generic drug, 

15 and— 

16 ‘‘(aa) in the case of a brand 

17 name drug, the wholesale acquisi18 tion cost, listed as cost per days 

19 supply and cost per dosage unit, 

20 on the date such drug was dis21 pensed; and 

22 ‘‘(bb) in the case of a ge23 neric drug, the average wholesale 

24 price, listed as cost per days sup25 ply and cost per dosage unit, on 


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1 the date such drug was dis2 pensed; and 

3 ‘‘(II) the total number of— 

4 ‘‘(aa) prescription claims 

5 (including original prescriptions 

6 and refills); 

7 ‘‘(bb) participants and bene8 ficiaries for whom a claim for 

9 such drug was filed; 

10 ‘‘(cc) dosage units per fill of 

11 such drug; and 

12 ‘‘(dd) days supply of such 

13 drug per fill; 

14 ‘‘(iv) the net price per course of treat15 ment or single fill, such as a 30-day supply 

16 or 90-day supply to the plan after manu17 facturer rebates, fees, and other remunera18 tion or adjustments; 

19 ‘‘(v) the total amount of out-of-pocket 

20 spending by participants and beneficiaries 

21 on such drug, including spending through 

22 copayments, coinsurance, and deductibles; 

23 ‘‘(vi) the total net spending by the 

24 plan; 


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1 ‘‘(vii) total amount received, or ex2 pected to be received, by the plan from any 

3 entity in drug manufacturer rebates, fees, 

4 alternative discounts, and all other remu5 neration received from an entity or any 

6 third party (including group purchasing or7 ganizations) other than the plan sponsor; 

8 ‘‘(viii) the total amount received, or 

9 expected to be received, by the plan from 

10 drug manufacturers in rebates, fees, alter11 native discounts, or other remuneration— 

12 ‘‘(I) that has been paid, or is to 

13 be paid, by drug manufacturers for 

14 claims incurred during the reporting 

15 period; and 

16 ‘‘(II) that is related to utilization 

17 rebates for such drug; and 

18 ‘‘(ix) to the extent feasible, informa19 tion on the total amount of remuneration, 

20 including copayment assistance dollars 

21 paid, copayment cards applied, or other 

22 discounts provided by each drug manufac23 turer (or entity administering copay assist24 ance on behalf of such drug manufacturer) 


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1 to the participants and beneficiaries en2 rolled in such plan; 

3 ‘‘(B) for each category or class of drugs 

4 for which a claim was filed, a breakdown of the 

5 total gross spending on drugs in such category 

6 or class before rebates, price concessions, alter7 native discounts, or other remuneration from 

8 drug manufacturers, and the net spending after 

9 such rebates, price concessions, alternative dis10 counts, or other remuneration from drug manu11 facturers, including— 

12 ‘‘(i) the number of participants and 

13 beneficiaries who filled a prescription for a 

14 drug in such category or class, including 

15 the National Drug Code for each such 

16 drug; 

17 ‘‘(ii) if applicable, a description of the 

18 formulary tiers and utilization mechanisms 

19 (such as prior authorization or step ther20 apy) employed for drugs in that category 

21 or class; and 

22 ‘‘(iii) the total out-of-pocket spending 

23 under the plan by participants and bene24 ficiaries, including spending through co25 payments, coinsurance, and deductibles; 


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1 ‘‘(C) in the case of a drug for which gross 

2 spending by such plan or entity exceeded 

3 $10,000 during the reporting period— 

4 ‘‘(i) a list of all other drugs in the 

5 same therapeutic category or class; and 

6 ‘‘(ii) the rationale for the formulary 

7 placement of such drug in that therapeutic 

8 category or class, if applicable; 

9 ‘‘(D) amounts paid directly or indirectly in 

10 rebates, fees, or any other type of compensation 

11 (as defined in section 408(b)(2)(B)(ii)(dd)(AA) 

12 of the Employee Retirement Income Security 

13 Act) to brokers, consultants, advisors, or any 

14 other individual or firm, for the referral of the 

15 group health plan’s business to an entity pro16 viding pharmacy benefits management services, 

17 including the identity of the recipient of such 

18 amounts; 

19 ‘‘(E) an explanation of any benefit design 

20 parameters that encourage or require partici21 pants, beneficiaries, and enrollees in such plan 

22 to fill prescriptions at mail order, specialty, or 

23 retail pharmacies that are affiliated with or 

24 under common ownership with the entity pro25 viding pharmacy benefit management services 


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1 under such plan, including mandatory mail and 

2 specialty home delivery programs, retail and 

3 mail auto-refill programs, and cost-sharing as4 sistance incentives directly or indirectly funded 

5 by such entity; and 

6 ‘‘(F) in the case of a plan (or an entity 

7 providing pharmacy benefits management serv8 ices on behalf of such plan) that has an affili9 ated pharmacy or pharmacy under common 

10 ownership— 

11 ‘‘(i) the percentage of total prescrip12 tions dispensed by such pharmacies to in13 dividuals enrolled in such plan; 

14 ‘‘(ii) a list of all drugs dispensed by 

15 such pharmacies to individuals enrolled in 

16 such plan and, with respect to each drug 

17 dispensed— 

18 ‘‘(I) the amount charged, per 

19 dosage unit, per 30-day supply, or per 

20 90-day supply (as applicable) to the 

21 plan and to participants and bene22 ficiaries enrolled in such plan; 

23 ‘‘(II) the median amount charged 

24 to such plan, and the interquartile 

25 range of the costs, per dosage unit, 


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1 per 30-day supply, and per 90-day 

2 supply, including amounts paid by the 

3 participants and beneficiaries, when 

4 the same drug is dispensed by other 

5 pharmacies that are not affiliated with 

6 or under common ownership with the 

7 entity and that are included in the 

8 pharmacy network of such plan; 

9 ‘‘(III) the lowest cost per dosage 

10 unit, per 30-day supply and per 90- 

11 day supply, for each such drug, in12 cluding amounts charged to the plan 

13 and to participants and beneficiaries, 

14 that is available from any pharmacy 

15 included in the network of such plan; 

16 and 

17 ‘‘(IV) the net acquisition cost per 

18 dosage unit, per 30-day supply, and 

19 per 90-day supply, if such drug is 

20 subject to a maximum price discount. 

21 ‘‘(3) PRIVACY REQUIREMENTS.—Health insur22 ance issuers offering group health insurance cov23 erage and entities providing pharmacy benefits man24 agement services on behalf of a group health plan 

25 shall provide information under paragraph (1) in a 


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1 manner consistent with the privacy, security, and 

2 breach notification regulations promulgated under 

3 section 13402(a) of the Health Information Tech4 nology for Clinical Health Act, and shall restrict the 

5 use and disclosure of such information according to 

6 such privacy regulations. 

7 ‘‘(4) DISCLOSURE AND REDISCLOSURE.— 

8 ‘‘(A) LIMITATION TO BUSINESS ASSOCI9 ATES.—A plan sponsor receiving a report under 

10 paragraph (1) may disclose such information 

11 only to the entity from which the report was re12 ceived, the group health plan for which the re13 port pertains, or to that entity’s business asso14 ciates as defined in section 160.103 of title 45, 

15 Code of Federal Regulations (or successor regu16 lations) or as permitted by the HIPAA Privacy 

17 Rule (45 CFR parts 160 and 164, subparts A 

18 and E). 

19 ‘‘(B) CLARIFICATION REGARDING PUBLIC

20 DISCLOSURE OF INFORMATION.—Nothing in 

21 this section shall prevent a group health plan or 

22 health insurance issuer offering group health 

23 insurance coverage, or an entity providing phar24 macy benefits management services on behalf of 

25 such a plan or coverage, from placing reasonVerDate Sep 11 2014 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00141 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 able restrictions on the public disclosure of the 

2 information contained in a report described in 

3 paragraph (1), except that such plan, issuer, or 

4 entity may not restrict disclosure of such report 

5 to the Department of Health and Human Serv6 ices, the Department of Labor, the Department 

7 of the Treasury, or the Comptroller General of 

8 the United States. 

9 ‘‘(C) LIMITED FORM OF REPORT.—The 

10 Secretary shall define through rulemaking a 

11 limited form of the report under paragraph (1) 

12 required of plan sponsors who are drug manu13 facturers, drug wholesalers, or other direct par14 ticipants in the drug supply chain, in order to 

15 prevent anti-competitive behavior. 

16 ‘‘(5) REPORT TO GAO.—A group health plan, or 

17 an entity providing pharmacy benefits management 

18 services on behalf of such plan, shall submit to the 

19 Comptroller General of the United States each of 

20 the first 4 reports submitted to a plan sponsor under 

21 paragraph (1) and other such reports as requested, 

22 in accordance with the privacy requirements under 

23 paragraph (3), the disclosure and redisclosure stand24 ards under paragraph (4), the standards specified 

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1 tion that the Comptroller General determines nec2 essary to carry out the study under section 106(d) 

3 of the Lower Costs, More Transparency Act. 

4 ‘‘(6) STANDARD FORMAT.—Not later than 1 

5 year after the date of enactment of this section, the 

6 Secretary shall specify through rulemaking stand7 ards for group health plans, and entities providing 

8 pharmacy benefits management services on behalf of 

9 such plans, required to submit reports under para10 graph (1) to submit such reports in a standard for11 mat. 

12 ‘‘(c) RULE OF CONSTRUCTION.—Nothing in this sec13 tion shall be construed to permit a group health plan or 

14 entity providing pharmacy benefits management services 

15 on behalf of such plan, to restrict disclosure to, or other16 wise limit the access of, the Secretary of Health and 

17 Human Services to a report described in subsection (b)(1) 

18 or information related to compliance with subsections (a) 

19 or (b) by entities subject to such subsection. 

20 ‘‘(d) DEFINITION.—In this section, the term ‘whole21 sale acquisition cost’ has the meaning given such term in 

22 section 1847A(c)(6)(B) of the Social Security Act.’’. 

23 (2) CLERICAL AMENDMENT.—The table of sec24 tions for subchapter B of chapter 100 of the InterVerDate Sep 11 2014 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00143 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 nal Revenue Code of 1986 is amended by adding at 

2 the end the following new item: 

‘‘Sec. 9826. Oversight of pharmacy benefits manager services.’’. 

3 (d) GAO REPORTS.— 

4 (1) REPORT ON PHARMACY NETWORK DE5 SIGN.— 

6 (A) IN GENERAL.—Not later than 3 years 

7 after the date of enactment of this Act, the 

8 Comptroller General of the United States shall 

9 submit to Congress a report on— 

10 (i) pharmacy networks that have con11 tracted with group health plans, health in12 surance issuers offering group health in13 surance coverage, or entities providing 

14 pharmacy benefits management services on 

15 behalf of such plans or issuers, including 

16 networks with pharmacies that are under 

17 common ownership (in whole or part) with 

18 such plans, issuers, or entities (including 

19 entities that provide pharmacy benefits ad20 ministrative services on behalf of such 

21 plans or issuers); 

22 (ii) pharmacy network design param23 eters that encourage individuals enrolled in 

24 such plans or coverage to fill prescriptions 

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1 macies that are wholly or partially owned 

2 by a plan, issuer, or entity; 

3 (iii) whether such plans and issuers 

4 have options to elect different network 

5 pricing arrangements in the marketplace 

6 with entities that provide pharmacy bene7 fits management services and the preva8 lence of electing such different network 

9 pricing arrangements; 

10 (iv) with respect to pharmacy net11 works that include pharmacies under com12 mon ownership described in clause (i)— 

13 (I) whether such networks are 

14 designed to encourage individuals en15 rolled in a group health plan or health 

16 insurance coverage to use such phar17 macies over other network pharmacies 

18 for specific services or drugs, and if 

19 so, the reasons the networks give for 

20 encouraging use of such pharmacies; 

21 and 

22 (II) whether such pharmacies are 

23 used by enrollees disproportionately 

24 more in the aggregate or for specific 


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1 services or drugs compared to other 

2 network pharmacies; 

3 (v) the degree to which mail order, 

4 specialty, or retail pharmacies that dis5 pense prescription drugs to an enrollee in 

6 a plan or coverage that are under common 

7 ownership (in whole or part) with plans, 

8 issuers, or entities providing pharmacy 

9 benefits management services or pharmacy 

10 benefits administrative services on behalf 

11 of such plan or coverage receive reimburse12 ment that is greater than the median price 

13 charged to the plan or issuer when the 

14 same drug is dispensed to enrollees in the 

15 plan or coverage by other pharmacies in16 cluded in the pharmacy network of that 

17 plan, issuer, or entity that are not wholly 

18 or partially owned by the plan or issuer, or 

19 entity providing pharmacy benefits man20 agement services on behalf of such plan or 

21 issuer. 

22 (B) REQUIREMENT.—The Comptroller 

23 General of the United States shall ensure that 

24 the report under subparagraph (A) does not 

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1 cific group health plan or health insurance 

2 issuer (or an entity providing pharmacy benefits 

3 management services on behalf of such plan or 

4 issuer), or otherwise contain commercial or fi5 nancial information that is privileged or con6 fidential. 

7 (C) DEFINITIONS.—In this paragraph, the 

8 terms ‘‘group health plan’’, ‘‘health insurance 

9 coverage’’, and ‘‘health insurance issuer’’ have 

10 the meanings given such terms in section 2791 

11 of the Public Health Service Act (42 U.S.C. 

12 300gg–91). 

13 (2) REPORT ON COPAY ASSISTANCE PRO14 GRAMS.—Not later than 18 months after the date of 

15 the enactment of this Act, the Comptroller General 

16 of the United States shall submit to Congress a re17 port on what is known about the role of copay as18 sistance programs and the impact of such programs 

19 on commercial health insurance, stop loss, and drug 

20 prices. Such report shall include to the extent fea21 sible— 

22 (A) a description of copay assistance pro23 grams, including— 

24 (i) the types of programs available 

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1 ance through such programs, including 

2 cash discounts, copay cards, or drugs pro3 vided to an individual at no cost; 

4 (ii) how such programs are funded; 

5 (iii) the types of entities that own, op6 erate, or otherwise conduct such programs, 

7 the types of information such entities col8 lect, and the direct and indirect contrac9 tual relationships between the entities in 

10 the drug supply chain that interact with 

11 such programs, such as a drug manufac12 turer, pharmacy, wholesaler, switch, rebate 

13 aggregator, pharmacy benefit manager, 

14 and other entities in the drug supply chain; 

15 (iv) the effect of such programs on 

16 patient out-of-pocket spending, including 

17 for stop-loss insurance, and drug utiliza18 tion, including drug adherence; and 

19 (v) patient eligibility criteria for such 

20 programs; and 

21 (B) an analysis of— 

22 (i) the sources of funding for such 

23 programs; and 

24 (ii) the effects of such programs on 

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1 viduals enrolled in such Federal health 

2 care programs. 

3 SEC. 107. REPORTS ON HEALTH CARE TRANSPARENCY 

4 TOOLS AND DATA. 

5 (a) INITIAL REPORT.—Not later than December 31, 

6 2024, the Comptroller General of the United States shall 

7 submit to the Committees (as defined in subsection (d)) 

8 an initial report that— 

9 (1) identifies and describes health care trans10 parency tools and Federal health care reporting re11 quirements (as described in subsection (d)) that are 

12 in effect as of the date of the submission of such ini13 tial report, including the frequency of reports with 

14 respect to each such requirement and whether any 

15 such requirements are duplicative; 

16 (2) reviews how such reporting requirements 

17 are enforced; 

18 (3) analyzes whether the public availability of 

19 health care transparency tools, and the publication 

20 of data pursuant to such reporting requirements, 

21 has— 

22 (A) been utilized and valued by consumers, 

23 including reasons for such utilization (or lack 

24 thereof); and 


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1 (B) assisted health insurance plan spon2 sors and fiduciaries improve benefits, lower 

3 health care costs for plan participants, and 

4 meet fiduciary requirements; 

5 (4) includes recommendations to the Commit6 tees, the Secretary of Health and Human Services, 

7 the Secretary of Labor, and the Secretary of the 

8 Treasury to— 

9 (A) improve the efficiency, accuracy, and 

10 usability of health care transparency tools; 

11 (B) streamline Federal health care report12 ing requirements to eliminate duplicative re13 quirements and reduce the burden on entities 

14 required to submit reports pursuant to such 

15 provisions; 

16 (C) improve the accuracy and efficiency of 

17 such reports while maintaining the integrity 

18 and usability of the data provided by such re19 ports; 

20 (D) address any gaps in data provided by 

21 such reports; and 

22 (E) ensure that the data and information 

23 reported is comparable and usable to con24 sumers, including patients, plan sponsors, and 

25 policy makers. 


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1 (b) FINAL REPORT.—Not later than December 31, 

2 2028, the Comptroller General of the United States shall 

3 submit to the Committees a report that includes— 

4 (1) the information provided in the initial re5 port, along with any updates to such information; 

6 and 

7 (2) any new information with respect to health 

8 care transparency tools that have been released fol9 lowing the submission of such initial report, or new 

10 reporting requirements in effect as of the date of the 

11 submission of the final report. 

12 (c) REPORT ON EXPANDING PRICE TRANSPARENCY

13 REQUIREMENTS.—Not later than December 31, 2025, the 

14 Comptroller General of the United States, in consultation 

15 with the Secretary of Health and Human Services, health 

16 care provider groups, and patient advocacy groups, shall 

17 submit to the Committees a report that includes rec18 ommendations to expand price transparency reporting re19 quirements to additional care settings, with an emphasis 

20 on settings where shoppable services (as defined in sub21 section (d)) are furnished. 

22 (d) DEFINITIONS.—In this section: 

23 (1) COMMITTEES.—The term ‘‘Committees’’ 

24 means the Committee on Ways and Means, the 

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1 mittee on Education and the Workforce of the 

2 House of Representatives, and the Committee on Fi3 nance and the Committee on Health, Education, 

4 Labor, and Pensions of the Senate. 

5 (2) FEDERAL HEALTH CARE REPORTING RE6 QUIREMENTS.—The term ‘‘Federal health care re7 porting requirements’’ includes regulatory and statu8 tory requirements with respect to the reporting and 

9 publication of health care price, cost access, and 

10 quality data, including requirements established by 

11 the Consolidated Appropriations Act of 2021 (Public 

12 Law 116–260), this Act, and other reporting and 

13 publication requirements with respect to trans14 parency in health care as identified by the Comp15 troller General of the United States. 

16 (3) SHOPPABLE SERVICE.—The term 

17 ‘‘shoppable service’’ means a service that can be 

18 scheduled by a health care consumer in advance and 

19 includes all ancillary items and services customarily 

20 furnished as part of such service. 

21 SEC. 108. REPORT ON INTEGRATION IN MEDICARE. 

22 (a) REQUIRED MA AND PDP REPORTING.— 

23 (1) MA PLANS.—Section 1857(e) of the Social 

24 Security Act (42 U.S.C. 1395w–27(e)) is amended 

25 by adding at the end the following new paragraph: 


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1 ‘‘(6) REQUIRED DISCLOSURE OF CERTAIN IN2 FORMATION RELATING TO HEALTH CARE PROVIDER

3 OWNERSHIP.— 

4 ‘‘(A) IN GENERAL.—For plan year 2025 

5 and for every third plan year thereafter, each 

6 applicable MA organization offering an MA 

7 plan under this part during such plan year shall 

8 submit to the Secretary, at a time and in a 

9 manner specified by the Secretary— 

10 ‘‘(i) the taxpayer identification num11 ber for each health care provider that was 

12 a specified health care provider with re13 spect to such organization during such 

14 year; 

15 ‘‘(ii) the total amount of incentive16 based payments made to, and the total 

17 amount of shared losses recoupments col18 lected from, such specified health care pro19 viders during such plan year; and 

20 ‘‘(iii) the total amount of incentive21 based payments made to, and the total 

22 amount of shared losses recoupments col23 lected from, providers of services and sup24 pliers not described in clause (ii) during 

25 such plan year. 


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1 ‘‘(B) DEFINITIONS.—For purposes of this 

2 paragraph: 

3 ‘‘(i) APPLICABLE MA ORGANIZA4 TION.—The term ‘applicable MA organiza5 tion’ means, with respect to a plan year, 

6 an MA organization with at least 25,000 

7 individuals enrolled under Medicare Advan8 tage plans offered by such organization 

9 during such plan year. 

10 ‘‘(ii) SPECIFIED HEALTH CARE PRO11 VIDER.—The term ‘specified health care 

12 provider’ means, with respect to an appli13 cable MA organization and a plan year, a 

14 provider of services or supplier with re15 spect to which such organization (or any 

16 person with an ownership or control inter17 est (as defined in section 1124(a)(3)) in 

18 such organization) is a person with an 

19 ownership or control interest (as so de20 fined).’’. 

21 (2) PRESCRIPTION DRUG PLANS.—Section 

22 1860D–12(b) of the Social Security Act (42 U.S.C. 

23 1395w–112(b)) is amended by adding at the end the 

24 following new paragraph: 


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1 ‘‘(9) PROVISION OF INFORMATION RELATING TO

2 PHARMACY OWNERSHIP.— 

3 ‘‘(A) IN GENERAL.—For plan year 2025 

4 and for every third plan year thereafter, each 

5 PDP sponsor offering a prescription drug plan 

6 under this part during such plan year shall sub7 mit to the Secretary, at a time and in a manner 

8 specified by the Secretary, the taxpayer identi9 fication number and National Provider Identi10 fier for each pharmacy that was a specified 

11 pharmacy with respect to such sponsor during 

12 such year. 

13 ‘‘(B) DEFINITION.—For purposes of this 

14 paragraph, the term ‘specified pharmacy’ 

15 means, with respect to an PDP sponsor offering 

16 a prescription drug plan and a plan year, a 

17 pharmacy with respect to which— 

18 ‘‘(i) such sponsor (or any person with 

19 an ownership or control interest (as de20 fined in section 1124(a)(3)) in such spon21 sor) is a person with an ownership or con22 trol interest (as so defined); or 

23 ‘‘(ii) a pharmacy benefit manager of24 fering services under such plan (or any 

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1 est (as so defined) in such sponsor) is a 

2 person with an ownership or control inter3 est (as so defined).’’. 

4 (b) MEDPAC REPORTS.—Part E of title XVIII of the 

5 Social Security Act (42 U.S.C. 1395x et seq.), as amended 

6 by section 101, is further amended by adding at the end 

7 the following new section: 

8 ‘‘SEC. 1899D. REPORTS ON VERTICAL INTEGRATION UNDER 

9 MEDICARE. 

10 ‘‘(a) IN GENERAL.—Not later than June 15, 2029, 

11 and every 3 years thereafter, the Medicare Payment Advi12 sory Commission shall submit to Congress a report on the 

13 state of vertical integration in the health care sector dur14 ing the applicable year with respect to entities partici15 pating in the Medicare program, including health care pro16 viders, pharmacies, prescription drug plan sponsors, Medi17 care Advantage organizations, and pharmacy benefit man18 agers. Such report shall include— 

19 ‘‘(1) with respect to Medicare Advantage orga20 nizations, the evaluation described in subsection (b); 

21 ‘‘(2) with respect to prescription drug plans, 

22 pharmacy benefit managers, and pharmacies, the 

23 comparisons and evaluations described in subsection 

24 (c); 


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1 ‘‘(3) with respect to Medicare Advantage plans 

2 under which benefits are available for physician-ad3 ministered drugs, the information described in sub4 section (d); 

5 ‘‘(4) the identifications described in subsection 

6 (e); and 

7 ‘‘(5) an analysis of the impact of such integra8 tion on health care access, price, quality, and out9 comes. 

10 ‘‘(b) MEDICARE ADVANTAGE ORGANIZATIONS.—For 

11 purposes of subsection (a)(1), the evaluation described in 

12 this subsection is, with respect to Medicare Advantage or13 ganizations and an applicable year, an evaluation, taking 

14 into account patient acuity and the types of areas serviced 

15 by such organization, of— 

16 ‘‘(1) the average number of qualifying diag17 noses made during such year with respect to enroll18 ees of a Medicare Advantage plan offered by such 

19 organization who, during such year, received a 

20 health risk assessment from a specified health care 

21 provider; 

22 ‘‘(2) the average risk score for such enrollees 

23 who received such an assessment during such year; 

24 ‘‘(3) any relationship between such risk scores 

25 for such enrollees receiving such an assessment from 


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1 such a provider during such year and incentive pay2 ments made to such providers; 

3 ‘‘(4) the average risk score for enrollees of such 

4 plan who received any item or service from a speci5 fied health care provider during such year; 

6 ‘‘(5) any relationship between the risk scores of 

7 enrollees under such plan and whether the enrollees 

8 have received any item or service from a specified 

9 provider; and 

10 ‘‘(6) any relationship between the risk scores of 

11 enrollees under such plan that have received any 

12 item or service from a specified provider and incen13 tive payments made under the plan to specified pro14 viders. 

15 ‘‘(c) PRESCRIPTION DRUG PLANS.—For purposes of 

16 subsection (a)(2), the comparisons and evaluations de17 scribed in this subsection are, with respect to prescription 

18 drug plans and an applicable year, the following: 

19 ‘‘(1) For each covered part D drug for which 

20 benefits are available under such a plan, a compari21 son of the average negotiated rate in effect with 

22 specified pharmacies with such rates in effect for in23 network pharmacies that are not specified phar24 macies. 

25 ‘‘(2) Comparisons of the following: 


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1 ‘‘(A) The total amount paid by pharmacy 

2 benefit managers to specified pharmacies for 

3 covered part D drugs and the total amount so 

4 paid to pharmacies that are not specified phar5 macies for such drugs. 

6 ‘‘(B) The total amount paid by such spon7 sors to specified pharmacy benefit managers as 

8 reimbursement for covered part D drugs and 

9 the total amount so paid to pharmacy benefit 

10 managers that are not specified pharmacy ben11 efit managers as such reimbursement. 

12 ‘‘(C) Fees paid under by plan to specified 

13 pharmacy benefit managers compared to such 

14 fees paid to pharmacy benefit managers that 

15 are not specified pharmacy benefit managers. 

16 ‘‘(3) An evaluation of the total amount of direct 

17 and indirect remuneration for covered part D drugs 

18 passed through to prescription drug plan sponsors 

19 and the total amount retained by pharmacy benefit 

20 managers (including entities under contract with 

21 such a manager). 

22 ‘‘(4) To the extent that the available data per23 mits, an evaluation of fees charged by rebate 

24 aggregators that are affiliated with plan sponsors. 


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1 ‘‘(d) PHYSICIAN-ADMINISTERED DRUGS.—For pur2 poses of subsection (a)(3), the information described in 

3 this subsection is, with respect to physician-administered 

4 drugs for which benefits are available under a Medicare 

5 Advantage plan during an applicable year, the following: 

6 ‘‘(1) With respect to each such plan, an identi7 fication of each drug for which benefits were avail8 able under such plan only when administered by a 

9 health care provider that acquired such drug from 

10 an affiliated pharmacy. 

11 ‘‘(2) An evaluation of the difference between 

12 the total number of drugs administered by a health 

13 care provider that were acquired from affiliated 

14 pharmacies compared to the number of such drugs 

15 so administered that were acquired from pharmacies 

16 other than affiliated pharmacies, and an evaluation 

17 of the difference in payments for such drugs so ad18 ministered when acquired from a specified pharmacy 

19 and when acquired from a pharmacy that is not a 

20 specified pharmacy. 

21 ‘‘(3) An evaluation of the dollar value of all 

22 such drugs that were not so administered because of 

23 a delay attributable to an affiliated pharmacy com24 pared to the dollar value of all such drugs that were 


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1 not so administered because of a delay attributable 

2 to pharmacy that is not an affiliated pharmacy. 

3 ‘‘(4) The number of enrollees administered such 

4 a drug that was acquired from an affiliated phar5 macy. 

6 ‘‘(5) The number of enrollees furnished such a 

7 drug that was acquired from a pharmacy that is not 

8 an affiliated pharmacy. 

9 ‘‘(e) IDENTIFICATIONS.—For purposes of subsection 

10 (a)(4), the identifications described in this subsection are, 

11 with respect to an applicable year, identifications of each 

12 health care entity participating under the Medicare pro13 gram with respect to which another health care entity so 

14 participating is a person with an ownership or control in15 terest (as defined in section 1124(a)(3)). 

16 ‘‘(f) DEFINITIONS.—In this section: 

17 ‘‘(1) AFFILIATED PHARMACY.—The term ‘affili18 ated pharmacy’ means, with respect to a Medicare 

19 Advantage plan offered by a Medicare Advantage or20 ganization, a pharmacy with respect to which such 

21 organization (or any person with an ownership or 

22 control interest (as defined in section 1124(a)(3)) in 

23 such organization) is a person with an ownership or 

24 control interest (as so defined). 


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1 ‘‘(2) APPLICABLE YEAR.—The term ‘applicable 

2 year’ means, with respect to a report submitted 

3 under subsection (a), the first calendar year begin4 ning at least 4 years prior to the date of the submis5 sion of such report. 

6 ‘‘(3) COVERED PART D DRUG.—The term ‘cov7 ered part D drug’ has the meaning given such term 

8 in section 1860D–2(e). 

9 ‘‘(4) DIRECT AND INDIRECT REMUNERATION.— 

10 The term ‘direct and indirect remuneration’ has the 

11 meaning given such term in section 423.308 of title 

12 42, Code of Federal Regulations (or any successor 

13 regulation). 

14 ‘‘(5) QUALIFYING DIAGNOSIS.—The term ‘quali15 fying diagnosis’ means, with respect to an enrollee of 

16 a Medicare Advantage plan, a diagnosis that is 

17 taken into account in calculating a risk score for 

18 such enrollee under the risk adjustment methodology 

19 established by the Secretary pursuant to section 

20 1853(a)(3). 

21 ‘‘(6) RISK SCORE.—The term ‘risk score’ 

22 means, with respect to an enrollee of a Medicare Ad23 vantage plan, the score calculated for such individual 

24 using the methodology described in paragraph (5). 


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1 ‘‘(7) PHYSICIAN-ADMINISTERED DRUG.—The 

2 term ‘physician-administered drug’ means a drug 

3 furnished to an individual that, had such individual 

4 been enrolled under part B and not enrolled under 

5 part C, would have been payable under section 

6 1842(o). 

7 ‘‘(8) SPECIFIED HEALTH CARE PROVIDER.— 

8 The term ‘specified health care provider’ means, 

9 with respect to a Medicare Advantage plan offered 

10 by a Medicare Advantage organization, a health care 

11 provider with respect to which such organization (or 

12 any person with an ownership or control interest (as 

13 defined in section 1124(a)(3)) in such organization) 

14 is a person with an ownership or control interest (as 

15 so defined). 

16 ‘‘(9) SPECIFIED PHARMACY.—The term ‘speci17 fied pharmacy’ means, with respect to a prescription 

18 drug plan offered by a prescription drug plan spon19 sor, a pharmacy with respect to which— 

20 ‘‘(A) such sponsor (or any person with an 

21 ownership or control interest (as defined in sec22 tion 1124(a)(3)) in such sponsor) is a person 

23 with an ownership or control interest (as so de24 fined); or 


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1 ‘‘(B) a pharmacy benefit manager offering 

2 services under such plan (or any person with an 

3 ownership or control interest (as so defined) in 

4 such sponsor) is a person with an ownership or 

5 control interest (as so defined). 

6 ‘‘(10) SPECIFIED PHARMACY BENEFIT MAN7 AGER.—The term ‘specified pharmacy benefit man8 ager’ means, with respect to a prescription drug 

9 plan offered by a prescription drug plan sponsor, a 

10 pharmacy benefit manager with respect to which 

11 such sponsor (or any person with an ownership or 

12 control interest (as defined in section 1124(a)(3)) in 

13 such sponsor) is a person with an ownership or con14 trol interest (as so defined).’’. 

15 SEC. 109. ADVISORY COMMITTEE. 

16 (a) IN GENERAL.—Not later than January 1, 2025, 

17 the Secretary of Labor, the Secretary of Health and 

18 Human Services, and the Secretary of the Treasury shall 

19 jointly convene an advisory committee (in this section re20 ferred to as the ‘‘committee’’) consisting of 9 members to 

21 advise the Secretaries on how to improve the usefulness, 

22 accessibility, and usability of information made available 

23 in accordance the amendments made by sections 105 and 

24 106, and by section 204 of division BB of the Consolidated 


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1 Appropriation Act, 2021 (Public Law 116–260), stream2 line the reporting of such information, and ensure that— 

3 (1) such information is accurate, accessible, and 

4 is delivered in a form and manner consistent with 

5 the requirements of such section; 

6 (2) the form and manner in which such infor7 mation is delivered is routinely updated in accord8 ance with widely-used practices in order to ensure 

9 accessibility; and 

10 (3) such information is available for audit (in11 cluding by making recommendations relating to how 

12 Federal and State actors may conduct such audits). 

13 (b) MEMBERSHIP.—The Secretaries shall jointly ap14 point members representing end-users of the information 

15 described in subsection (a). Vacancies on the committee 

16 shall be filled by appointment consistent with this sub17 section not later than 3 months after the vacancy arises. 

18 (c) TERMINATION.—The committee shall terminate 

19 on January 1, 2028. 

20 (d) NONAPPLICAITON OF FACA.—The Federal Advi21 sory Committee Act (5 U.S.C. App.) shall not apply to 

22 the committee. 


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1 SEC. 110. REPORT ON IMPACT OF MEDICARE REGULATIONS 

2 ON PROVIDER AND PAYER CONSOLIDATION. 

3 (a) ANNUAL REPORT ON THE IMPACT OF CERTAIN

4 MEDICARE REGULATIONS ON PROVIDER AND PAYER

5 CONSOLIDATION; PUBLIC COMMENT ON PROVIDER AND

6 PAYER CONSOLIDATION FOR CERTAIN PROPOSED

7 RULES.— 

8 (1) ANNUAL REPORT.—Not later than Decem9 ber 30, 2026, and annually thereafter, the Secretary 

10 of Health and Human Services (in this section re11 ferred to as the ‘‘Secretary’’) shall submit to Con12 gress a report on the impact in the aggregate on 

13 provider and payer consolidation with respect to reg14 ulations for parts A, B, C, and D of title XVIII of 

15 the Social Security Act (42 U.S.C. 1395 et seq.) im16 plemented in the calendar year immediately prior to 

17 such report. Such report shall include regulations 

18 that— 

19 (A) implement a change to an applicable 

20 payment system, a rate schedule, or another 

21 payment system under part A, B, C, or D of 

22 such title; or 

23 (B) result in a significant rule effecting 

24 provider or payer consolidation. 

25 (2) PUBLIC COMMENT ON IMPACT TO PROVIDER

26 AND PAYER CONSOLIDATION.—Beginning for 2025, 


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1 as part of any notice and comment rulemaking proc2 ess that will result in a significant rule effecting pro3 vider or payer consolidation with respect to a pro4 posed rule for parts A, B, C, and D of title XVIII 

5 of the Social Security Act (42 U.S.C. 1395j et seq.), 

6 the Secretary shall seek public comment on the pro7 jected impact of such proposed rule on provider and 

8 payer consolidation in the aggregate. 

9 (3) DEFINITIONS.—In this section: 

10 (A) PROVIDER AND PAYER CONSOLIDA11 TION.—The term ‘‘provider and payer consoli12 dation’’ includes the vertical or horizontal inte13 gration among providers of services (as defined 

14 in subsection (u) of section 1861 of the Social 

15 Security Act (42 U.S.C. 1395x)), suppliers (as 

16 defined in subsection (d) of such section), ac17 countable care organizations under section 1899 

18 of the Social Security Act (42 U.S.C. 1395jjj), 

19 Medicare Advantage organizations, PDP spon20 sors, pharmacy benefit managers, pharmacies, 

21 and integrated delivery systems. 

22 (B) APPLICABLE PAYMENT SYSTEM.—The 

23 term ‘‘applicable payment system’’ includes— 

24 (i) with respect to outpatient hospital 

25 services, the prospective payment system 


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1 for covered OPD services established under 

2 section 1833(t) of such Act (42 U.S.C. 

3 1395(l)); and 

4 (ii) with respect to physicians’ serv5 ices, the physician fee schedules established 

6 under section 1848 of such Act (42 U.S.C. 

7 1395w–4). 

8 (b) CONSIDERATION OF EFFECTS ON PROVIDER AND

9 PAYER CONSOLIDATION WITH RESPECT TO CMI MOD10 ELS.— 

11 (1) IN GENERAL.—Section 1115A(b)(4)(A) of 

12 the Social Security Act (42 U.S.C. 1315a(b)(4)(A)) 

13 is amended— 

14 (A) in clause (i), by striking at the end 

15 ‘‘and’’; 

16 (B) in clause (ii), by striking the period at 

17 the end and inserting ‘‘; and’’; and 

18 (C) by adding at the end the following new 

19 clause: 

20 ‘‘(iii) the extent to which, and how, 

21 the model has effected and could effect 

22 provider and payer consolidation, which in23 cludes the vertical or horizontal integration 

24 among providers of services (as defined in 

25 subsection (u) of section 1861), suppliers 


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1 (as defined in subsection (d) of such sec2 tion), and accountable care organizations 

3 under section 1899.’’. 

4 (2) EFFECTIVE DATE.—The amendments made 

5 by paragraph (1) shall apply with respect to models 

6 tested on or after January 1, 2025. 

7 SEC. 111. IMPLEMENTATION FUNDING. 

8 (a) IN GENERAL.—For the purposes described in 

9 subsection (b), there are appropriated, out of amounts in 

10 the Treasury not otherwise appropriated, to the Secretary 

11 of Health and Human Services and the Secretary of the 

12 Treasury, $25,000,000 for fiscal year 2024, to remain 

13 available through fiscal year 2029. 

14 (b) PERMITTED PURPOSES.—The purposes described 

15 in this subsection are the following purposes, insofar as 

16 such purposes are to carry out the provisions of, including 

17 the amendments made by, this title: 

18 (1) Preparing, drafting, and issuing proposed 

19 and final regulations or interim regulations. 

20 (2) Preparing, drafting, and issuing guidance 

21 and public information. 

22 (3) Preparing, drafting, and publishing reports. 

23 (4) Enforcement of such provisions. 

24 (5) Reporting, collection, and analysis of data. 


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1 (6) Other administrative duties necessary for 

2 implementation of such provisions. 

3 (c) TRANSPARENCY OF IMPLEMENTATION FUNDS.— 

4 Each Secretary described in subsection (a) shall annually 

5 submit, no later than September 1st of each year, to the 

6 Committees on Energy and Commerce, on Ways and 

7 Means, on Education and Workforce, and on Appropria8 tions of the House of Representatives and on the Commit9 tees on Health, Education, Labor, and Pensions and on 

10 Appropriations of the Senate a report on funds expended 

11 pursuant to funds appropriated under this section. 

12 TITLE II—REDUCING HEALTH 

13 CARE COSTS FOR PATIENTS 

14 SEC. 201. INCREASING TRANSPARENCY IN GENERIC DRUG 

15 APPLICATIONS. 

16 (a) IN GENERAL.—Section 505(j)(3) of the Federal 

17 Food, Drug, and Cosmetic Act (21 U.S.C. 355(j)(3)) is 

18 amended by adding at the end the following: 

19 ‘‘(H)(i) Upon request (in controlled correspondence 

20 or an analogous process) by a person that has submitted 

21 or intends to submit an abbreviated application under this 

22 subsection for a drug that is required by regulation to con23 tain one or more of the same inactive ingredients in the 

24 same concentrations as the listed drug referred to, or for 

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1 tification for an approach that is in vitro in whole or in 

2 part to be used to demonstrate bioequivalence for a drug 

3 if such a drug contains one or more of the same inactive 

4 ingredients in the same concentrations as the listed drug, 

5 the Secretary shall inform the person whether such drug 

6 is qualitatively and quantitatively the same as the listed 

7 drug. The Secretary may also provide such information 

8 to such a person on the Secretary’s own initiative during 

9 the review of an abbreviated application under this sub10 section for such drug. 

11 ‘‘(ii) Notwithstanding section 301(j), if the Secretary 

12 determines that such drug is not qualitatively or quan13 titatively the same as the listed drug, the Secretary shall 

14 identify and disclose to the person— 

15 ‘‘(I) the ingredient or ingredients that cause 

16 such drug not to be qualitatively or quantitatively 

17 the same as the listed drug; and 

18 ‘‘(II) for any ingredient for which there is an 

19 identified quantitative deviation, the amount of such 

20 deviation. 

21 ‘‘(iii) If the Secretary determines that such drug is 

22 qualitatively and quantitatively the same as the listed 

23 drug, the Secretary shall not change or rescind such deter24 mination after the submission of an abbreviated applica25 tion for such drug under this subsection unless— 


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1 ‘‘(I) the formulation of the listed drug has been 

2 changed and the Secretary has determined that the 

3 prior listed drug formulation was withdrawn for rea4 sons of safety or effectiveness; or 

5 ‘‘(II) the Secretary makes a written determina6 tion that the prior determination must be changed 

7 because an error has been identified. 

8 ‘‘(iv) If the Secretary makes a written determination 

9 described in clause (iii)(II), the Secretary shall provide no10 tice and a copy of the written determination to the person 

11 making the request under clause (i). 

12 ‘‘(v) The disclosures required by this subparagraph 

13 are disclosures authorized by law, including for purposes 

14 of section 1905 of title 18, United States Code.’’. 

15 (b) GUIDANCE.— 

16 (1) IN GENERAL.—Not later than one year 

17 after the date of enactment of this Act, the Sec18 retary of Health and Human Services shall issue 

19 draft guidance, or update guidance, describing how 

20 the Secretary will determine whether a drug is quali21 tatively and quantitatively the same as the listed 

22 drug (as such terms are used in section 

23 505(j)(3)(H) of the Federal Food, Drug, and Cos24 metic Act, as added by subsection (a)), including 

25 with respect to assessing pH adjusters. 


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1 (2) PROCESS.—In issuing guidance under this 

2 subsection, the Secretary of Health and Human 

3 Services shall— 

4 (A) publish draft guidance; 

5 (B) provide a period of at least 60 days for 

6 comment on the draft guidance; and 

7 (C) after considering any comments re8 ceived and not later than one year after the 

9 close of the comment period on the draft guid10 ance, publish final guidance. 

11 (c) APPLICABILITY.—Section 505(j)(3)(H) of the 

12 Federal Food, Drug, and Cosmetic Act, as added by sub13 section (a), applies beginning on the date of enactment 

14 of this Act, irrespective of the date on which the guidance 

15 required by subsection (b) is finalized. 

16 SEC. 202. IMPROVING TRANSPARENCY AND PREVENTING 

17 THE USE OF ABUSIVE SPREAD PRICING AND 

18 RELATED PRACTICES IN MEDICAID. 

19 (a) PHARMACY PRICE REIMBURSEMENT REQUIRE20 MENTS.— 

21 (1) IN GENERAL.—Section 1927(e) of the So22 cial Security Act (42 U.S.C. 1396r–8(e)) is amended 

23 by adding at the end the following: 

24 ‘‘(6) PHARMACY PRICE REIMBURSEMENT RE25 QUIRED.— 


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1 ‘‘(A) IN GENERAL.—A contract between 

2 the State and a pharmacy benefit manager (in 

3 this paragraph referred to as a ‘PBM’), or a 

4 contract between the State and a designated en5 tity (as defined in subparagraph (C)) that in6 cludes provisions making the designated entity 

7 responsible for the administration of medical 

8 assistance consisting of covered outpatient 

9 drugs for individuals enrolled with the des10 ignated entity, shall require that payment for 

11 such drugs and related administrative services 

12 (as applicable), including payments made by a 

13 PBM on behalf of the State or designated enti14 ty, is based on pharmacy price reimbursement 

15 model under which— 

16 ‘‘(i) any payment made by the des17 ignated entity or the PBM (as applicable) 

18 for such a drug— 

19 ‘‘(I) is limited to— 

20 ‘‘(aa) ingredient cost; and 

21 ‘‘(bb) a professional dis22 pensing fee that is not less than 

23 the professional dispensing fee 

24 that the State plan or waiver 


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1 would pay if the plan or waiver 

2 was making the payment directly; 

3 ‘‘(II) is passed through in its en4 tirety by the designated entity or 

5 PBM to the pharmacy or provider 

6 that dispenses the drug and is not 

7 retroactively denied or reduced except 

8 as the result of an audit performed 

9 pursuant to a contract between such 

10 designated entity or PBM and such 

11 pharmacy or provider, or as otherwise 

12 permitted or required by law (includ13 ing in response to instances of fraud, 

14 waste, or abuse); and 

15 ‘‘(III) is made in a manner that 

16 is consistent with sections 447.502, 

17 447.512, 447.514, and 447.518 of 

18 title 42, Code of Federal Regulations 

19 (or any successor regulation) as if 

20 such requirements applied directly to 

21 the designated entity or the PBM, ex22 cept that any payment by the des23 ignated entity or the PBM for the in24 gredient cost of such a drug pur25 chased by a covered entity (as defined 


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1 in subsection (a)(5)(B)) may exceed 

2 the actual acquisition cost (as defined 

3 in section 447.502 of title 42, Code of 

4 Federal Regulations (or any successor 

5 regulation)) for such drug if— 

6 ‘‘(aa) such drug was subject 

7 to an agreement under section 

8 340B of the Public Health Serv9 ice Act; 

10 ‘‘(bb) such payment for such 

11 cost of such drug does not exceed 

12 the maximum payment that 

13 would have been made by the 

14 designated entity or the PBM for 

15 the ingredient cost of such drug 

16 had such drug not been pur17 chased by such a covered entity; 

18 and 

19 ‘‘(cc) such covered entity re20 ports to the Secretary, on an an21 nual basis (in a form and manner 

22 specified by the Secretary) and 

23 with respect to payments for 

24 such costs of such drugs so pur25 chased by such covered entity 


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1 that are in excess of the actual 

2 acquisition costs for such drugs, 

3 the aggregate amount of such ex4 cess; 

5 ‘‘(ii) payment to the designated entity 

6 or the PBM (as applicable) for administra7 tive services performed by the designated 

8 entity or PBM is limited to an administra9 tive fee that reflects the fair market value 

10 of providing such services; 

11 ‘‘(iii) the designated entity or the 

12 PBM (as applicable) makes available to 

13 the State, and the Secretary upon request, 

14 all costs and payments related to covered 

15 outpatient drugs and accompanying admin16 istrative services incurred, received, or 

17 made by the designated entity or the PBM, 

18 including ingredient costs, professional dis19 pensing fees, administrative fees, post-sale 

20 and post-invoice fees, discounts, or related 

21 adjustments such as direct and indirect re22 muneration fees, and any and all other re23 muneration; and 

24 ‘‘(iv) any form of spread pricing 

25 whereby any amount charged or claimed by 


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1 the designated entity or the PBM (as ap2 plicable) is in excess of the amount paid to 

3 the pharmacies by the designated entity or 

4 the PBM, including any post-sale or post5 invoice fees, discounts, or related adjust6 ments such as direct and indirect remu7 neration fees or assessments (after allow8 ing for a fair market administrative fee as 

9 described in clause (ii)), is not allowable 

10 for purposes of claiming Federal matching 

11 payments under this title. 

12 ‘‘(B) MAKING CERTAIN INFORMATION

13 AVAILABLE.—The Secretary shall publish, not 

14 less frequently than on an annual basis, infor15 mation received by the Secretary pursuant to 

16 subparagraph (A)(i)(III)(cc). Such information 

17 shall be so published in an electronic and 

18 searchable format, such as through the 340B 

19 Office of Pharmacy Affairs Information System 

20 (or a successor system). 

21 ‘‘(C) DEFINITIONS.—In this paragraph: 

22 ‘‘(i) DESIGNATED ENTITY.—The term 

23 ‘designated entity’ means a managed care 

24 entity or other specified entity. 


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1 ‘‘(ii) MANAGED CARE ENTITY; OTHER

2 SPECIFIED ENTITY.—The terms ‘managed 

3 care entity’ and ‘other specified entity’ 

4 have the meaning given such terms in sec5 tion 1903(m)(9)(D).’’. 

6 (2) CONFORMING AMENDMENTS.—Section 

7 1903(m)(2)(A) of such Act (42 U.S.C. 

8 1396b(m)(2)(A)) is amended— 

9 (A) in clause (i), by inserting before the 

10 semicolon at the end the following: ‘‘(or, in the 

11 case of a contract described in section 

12 1927(e)(6), is an other specified entity (as de13 fined in paragraph (9)(D))’’; and 

14 (B) in clause (xiii)— 

15 (i) by striking ‘‘and (III)’’ and insert16 ing ‘‘(III)’’; 

17 (ii) by inserting before the period at 

18 the end the following: ‘‘, and (IV) the 

19 pharmacy benefit provided by the entity 

20 (or pharmacy benefit manager on behalf of 

21 the entity under a contract), the other 

22 specified entity (as defined in paragraph 

23 (9)(D)) (or pharmacy benefit manager on 

24 behalf of the other specified entity under a 

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1 tween the entity or other specified entity 

2 and the pharmacy benefit manager, shall 

3 comply with the requirements of section 

4 1927(e)(6)’’; and 

5 (iii) by moving the margin 2 ems to 

6 the left. 

7 (3) EFFECTIVE DATE.—The amendments made 

8 by this subsection apply to contracts between States 

9 and pharmacy benefit managers and designated enti10 ties (as defined in section 1927(e)(6) of the Social 

11 Security Act, as added by paragraph (1)) that have 

12 an effective date beginning on or after the date that 

13 is 18 months after the date of enactment of this Act. 

14 (b) ENSURING ACCURATE PAYMENTS TO PHAR15 MACIES UNDER MEDICAID.— 

16 (1) IN GENERAL.—Section 1927(f) of the Social 

17 Security Act (42 U.S.C. 1396r–8(f)) is amended— 

18 (A) by striking ‘‘and’’ after the semicolon 

19 at the end of paragraph (1)(A)(i) and all that 

20 precedes it through ‘‘(1)’’ and inserting the fol21 lowing: 

22 ‘‘(1) DETERMINING PHARMACY ACTUAL ACQUI23 SITION COSTS.—The Secretary shall conduct a sur24 vey of retail community pharmacy drug prices to deVerDate Sep 11 2014 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00180 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 termine the national average drug acquisition cost as 

2 follows: 

3 ‘‘(A) USE OF VENDOR.—The Secretary 

4 may contract services for— 

5 ‘‘(i) with respect to retail community 

6 pharmacies, the determination of retail 

7 survey prices of the national average drug 

8 acquisition cost for covered outpatient 

9 drugs based on a monthly survey of such 

10 pharmacies; and’’; 

11 (B) by adding at the end of paragraph (1) 

12 the following: 

13 ‘‘(F) SURVEY REPORTING.—A State shall 

14 require that any retail community pharmacy in 

15 the State that receives any payment, reimburse16 ment, administrative fee, discount, or rebate re17 lated to the dispensing of covered outpatient 

18 drugs to individuals receiving benefits under 

19 this title, regardless of whether such payment, 

20 reimbursement, administrative fee, discount, or 

21 rebate is received from the State or a des22 ignated entity (as defined in subsection 

23 (e)(6)(C)) directly or from a pharmacy benefit 

24 manager that has a contract with the State or 


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1 a designated entity, shall respond to surveys of 

2 retail prices conducted under this subsection. 

3 ‘‘(G) SURVEY INFORMATION.—Information 

4 on national drug acquisition prices obtained 

5 under this paragraph shall be made publicly 

6 available in a timely manner following the col7 lection of such information and shall include at 

8 least the following: 

9 ‘‘(i) The monthly response rate to the 

10 survey including a list of pharmacies not in 

11 compliance with subparagraph (F). 

12 ‘‘(ii) The sampling frame and number 

13 of pharmacies sampled monthly. 

14 ‘‘(iii) Information on price concessions 

15 to the pharmacy, including discounts, re16 bates, and other price concessions, to the 

17 extent that such information may be pub18 licly released and is available during the 

19 survey period. 

20 ‘‘(H) REPORT ON SPECIALTY PHAR21 MACIES.—Not later than 1 year after the date 

22 that this subparagraph takes effect, the Sec23 retary shall submit to Congress a report exam24 ining specialty drug coverage and reimburse25 ment under this title, including— 


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1 ‘‘(i) a description of how State Med2 icaid programs define specialty drugs and 

3 specialty pharmacies; 

4 ‘‘(ii) the amount State Medicaid pro5 grams pay for specialty drugs; 

6 ‘‘(iii) how States and designated enti7 ties (as defined in subsection (e)(6)(C)) de8 termine payment for specialty drugs; 

9 ‘‘(iv) the settings in which specialty 

10 drugs are dispensed to individuals receiv11 ing benefits under this title (such as retail 

12 community pharmacies or specialty phar13 macies); 

14 ‘‘(v) the extent to which specialty 

15 drugs (as defined by the respective States) 

16 are captured in the national average drug 

17 acquisition cost survey (or through another 

18 process); 

19 ‘‘(vi) examples of specialty drug dis20 pensing fees to support the services associ21 ated with dispensing such specialty drugs; 

22 and 

23 ‘‘(vii) recommendations as to whether 

24 specialty pharmacies should be included in 

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1 tional average drug acquisition costs cap2 ture drugs sold at specialty pharmacies, 

3 and how such specialty pharmacies should 

4 be defined. 

5 ‘‘(I) ENFORCEMENT.—At the discretion of 

6 the Secretary, the Secretary (acting through the 

7 Inspector General and in collaboration with the 

8 Administrator of the Centers for Medicare & 

9 Medicaid Services) may enforce non-compliance 

10 with this paragraph by a pharmacy through the 

11 establishment of penalties until compliance with 

12 this paragraph has been completed.’’; and 

13 (C) in paragraph (2)— 

14 (i) in subparagraph (A), by inserting 

15 ‘‘(including payment rates under managed 

16 care organization as defined in section 

17 1932(a)(1)(B)(i) and PIHPs and PAHPs 

18 as defined in section 1903(m)(9)(D)(iii)(I) 

19 and (II), respectively)’’ after ‘‘under this 

20 title’’; and 

21 (ii) in subparagraph (B), by inserting 

22 ‘‘, and the basis for such dispensing fees’’ 

23 before the semicolon at the end. 

24 (2) EFFECTIVE DATE.—The amendments made 

25 by this subsection shall take effect on the first day 


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1 of the first quarter that begins on or after the date 

2 that is 18 months after the date of enactment of 

3 this Act. 

4 SEC. 203. PARITY IN MEDICARE PAYMENTS FOR HOSPITAL 

5 OUTPATIENT DEPARTMENT SERVICES FUR6 NISHED OFF-CAMPUS. 

7 (a) IN GENERAL.—Section 1833(t)(16) of the Social 

8 Security Act (42 U.S.C. 1395l(t)(16)) is amended by add9 ing at the end the following new subparagraph: 

10 ‘‘(H) PARITY IN FEE SCHEDULE AMOUNT

11 FOR CERTAIN SERVICES FURNISHED BY AN

12 OFF-CAMPUS OUTPATIENT DEPARTMENT OF A

13 PROVIDER.— 

14 ‘‘(i) IN GENERAL.—Subject to clause 

15 (iii), in the case of specified OPD services 

16 (as defined in clause (v)) that are fur17 nished during 2025 or a subsequent year 

18 by an off-campus outpatient department of 

19 a provider (as defined in clause (iv)) (or, 

20 in the case of an off-campus outpatient de21 partment of a provider that is a hospital 

22 described in section 1886(d)(1)(B)(v), or is 

23 located in a rural area or a health profes24 sional shortage area, such services that are 

25 furnished during 2026 or a subsequent 


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1 year), there shall be substituted for the 

2 amount otherwise determined under this 

3 subsection for such service and year an 

4 amount equal to the payment amount that 

5 would have been payable under the applica6 ble payment system under this part (other 

7 than under this subsection) had such serv8 ices been furnished by such a department 

9 subject to such payment system pursuant 

10 to paragraph (21)(C). 

11 ‘‘(ii) NOT BUDGET NEUTRAL IMPLE12 MENTATION.—In making any budget neu13 trality adjustments under this subsection 

14 for 2025 or a subsequent year, the Sec15 retary shall not take into account the re16 duced expenditures that result from the 

17 application of this subparagraph. 

18 ‘‘(iii) TRANSITION.—The Secretary 

19 shall provide for a 4-year phase-in of the 

20 application of clause (i), with clause (i) 

21 being fully applicable for specified OPD 

22 services beginning with 2028 (or in the 

23 case of an off-campus outpatient depart24 ment of a provider that is a hospital de25 scribed in section 1886(d)(1)(B)(v), or is 


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1 located in a rural area or a health profes2 sional shortage area, beginning with 2029). 

3 ‘‘(iv) OFF-CAMPUS DEPARTMENT OF A

4 PROVIDER.—For purposes of this subpara5 graph, the term ‘off-campus outpatient de6 partment of a provider’ means a depart7 ment of a provider (as defined in section 

8 413.65(a)(2) of title 42, Code of Federal 

9 Regulations) that is not located— 

10 ‘‘(I) on the campus (as such term 

11 is defined in such section) of such 

12 provider; or 

13 ‘‘(II) within the distance (de14 scribed in such definition of campus) 

15 from a remote location of a hospital 

16 facility (as defined in such section). 

17 ‘‘(v) OTHER DEFINITIONS.—For pur18 poses of this subparagraph: 

19 ‘‘(I) DESIGNATED AMBULATORY

20 PAYMENT CLASSIFICATION GROUP.— 

21 The term ‘designated ambulatory pay22 ment classification group’ means an 

23 ambulatory payment classification 

24 group for drug administration serv25 ices. 


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1 ‘‘(II) HEALTH PROFESSIONAL

2 SHORTAGE AREA.—The term ‘health 

3 professional shortage area’ has the 

4 meaning given such term in section 

5 332(a)(1)(A) of the Public Health 

6 Service Act. 

7 ‘‘(III) RURAL AREA.—The term 

8 ‘rural area’ has the meaning given 

9 such term in section 1886(d)(2)(D). 

10 ‘‘(IV) SPECIFIED OPD SERV11 ICES.—The term ‘specified OPD serv12 ices’ means covered OPD services as13 signed to a designated ambulatory 

14 payment classification group.’’. 

15 (b) IMPLEMENTATION.—Section 1833(t)(12) of the 

16 Social Security Act (42 U.S.C. 1395l(t)(12)) is amend17 ed— 

18 (1) in subparagraph (D), by striking ‘‘and’’ at 

19 the end; 

20 (2) in subparagraph (E), by striking the period 

21 at the end and inserting ‘‘; and’’; and 

22 (3) by adding at the end the following new sub23 paragraph: 

24 ‘‘(F) the determination of any payment 

25 amount under paragraph (16)(H), including the 


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1 transition under clause (iii) of such para2 graph.’’. 

3 SEC. 204. REQUIRING A SEPARATE IDENTIFICATION NUM4 BER AND AN ATTESTATION FOR EACH OFF5 CAMPUS OUTPATIENT DEPARTMENT OF A 

6 PROVIDER. 

7 (a) IN GENERAL.—Section 1833(t) of the Social Se8 curity Act (42 U.S.C. 1395l(t)) is amended by adding at 

9 the end the following new paragraph: 

10 ‘‘(23) USE OF UNIQUE HEALTH IDENTIFIERS; 

11 ATTESTATION.— 

12 ‘‘(A) IN GENERAL.—No payment may be 

13 made under this subsection (or under an appli14 cable payment system pursuant to paragraph 

15 (21)) for items and services furnished on or 

16 after January 1, 2026, by an off-campus out17 patient department of a provider (as defined in 

18 subparagraph (C)) unless— 

19 ‘‘(i) such department has obtained, 

20 and such items and services are billed 

21 under, a standard unique health identifier 

22 for health care providers (as described in 

23 section 1173(b)) that is separate from 

24 such identifier for such provider; and 


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1 ‘‘(ii) such provider has submitted to 

2 the Secretary, during the 2-year period 

3 ending on the date such items and services 

4 are so furnished, an attestation that such 

5 department is compliant with the require6 ments described in section 413.65 of title 

7 42, Code of Federal Regulations (or a suc8 cessor regulation). 

9 ‘‘(B) PROCESS FOR SUBMISSION AND RE10 VIEW.—Not later than 1 year after the date of 

11 enactment of this paragraph, the Secretary 

12 shall, through notice and comment rulemaking, 

13 establish a process for each provider with an 

14 off-campus outpatient department of a provider 

15 to submit an attestation pursuant to subpara16 graph (A)(ii), and for the Secretary to review 

17 each such attestation and determine, through 

18 site visits, remote audits, or other means (as 

19 determined appropriate by the Secretary), 

20 whether such department is compliant with the 

21 requirements described in such subparagraph. 

22 ‘‘(C) OFF-CAMPUS OUTPATIENT DEPART23 MENT OF A PROVIDER DEFINED.—For purposes 

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1 partment of a provider (as defined in section 

2 413.65 of title 42, Code of Federal Regulations, 

3 or any successor regulation) that is not lo4 cated— 

5 ‘‘(i) on the campus (as defined in such 

6 section) of such provider; or 

7 ‘‘(ii) within the distance (described in 

8 such definition of campus) from a remote 

9 location of a hospital facility (as defined in 

10 such section).’’. 

11 (b) HHS OIG ANALYSIS.—Not later than January 

12 1, 2030, the Inspector General of the Department of 

13 Health and Human Services shall submit to Congress— 

14 (1) an analysis of the process established by the 

15 Secretary of Health and Human Services to conduct 

16 the reviews and determinations described in section 

17 1833(t)(23)(B) of the Social Security Act, as added 

18 by subsection (a) of this section; and 

19 (2) recommendations based on such analysis, as 

20 the Inspector General determines appropriate. 


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1 TITLE III—SUPPORTING PA2 TIENTS, HEALTH CARE WORK3 ERS, COMMUNITY HEALTH 

4 CENTERS, AND HOSPITALS 

5 SEC. 301. EXTENSION FOR COMMUNITY HEALTH CENTERS, 

6 THE NATIONAL HEALTH SERVICE CORPS, 

7 AND TEACHING HEALTH CENTERS THAT OP8 ERATE GME PROGRAMS. 

9 (a) TEACHING HEALTH CENTERS THAT OPERATE

10 GRADUATE MEDICAL EDUCATION PROGRAMS.— 

11 (1) ADDITION TO CAPPED AMOUNTS FOR FIS12 CAL YEARS 2024 AND 2025.—Paragraph (2) of section 

13 340H(b) of the Public Health Service Act (42 

14 U.S.C. 256h(b)) is amended by adding at the end 

15 the following: 

16 ‘‘(C) ADDITION.—Notwithstanding any 

17 provision of this section, for each of fiscal years 

18 2024 and 2025, the Secretary may use any 

19 amounts made available in any fiscal year to 

20 carry out this section (including amounts re21 couped under subsection (f)) to make payments 

22 described in paragraphs (1)(A) and (1)(B), in 

23 addition to the total amount of funds appro24 priated under subsection (g).’’. 


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1 (2) RECONCILIATION.—Section 340H(f) of the 

2 Public Health Service Act (42 U.S.C. 256h(f)) is 

3 amended— 

4 (A) by striking ‘‘The Secretary shall deter5 mine’’ and inserting the following: 

6 ‘‘(1) DETERMINATION.—The Secretary shall de7 termine’’; and 

8 (B) by adding at the end the following: 

9 ‘‘(2) ANNUAL REPORT TO CONGRESS.—For 

10 each fiscal year, the Secretary shall submit to the 

11 Committee on Energy and Commerce of the House 

12 of Representatives and the Committee on Health, 

13 Education, Labor, and Pensions of the Senate a re14 port specifying— 

15 ‘‘(A) the total amount of funds recouped 

16 under paragraph (1); 

17 ‘‘(B) the rationale for the funds being re18 couped; and 

19 ‘‘(C) in the case of the reports for each of 

20 fiscal years 2024 and 2025, the total amount of 

21 funds recouped under paragraph (1) that were 

22 used pursuant to subsection (b)(2)(C) to adjust 

23 total payment amounts above the total amounts 

24 appropriated under subsection (g).’’. 


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1 (3) FUNDING.—Section 340H(g) of the Public 

2 Health Service Act (42 U.S.C. 256h(g)) is amend3 ed— 

4 (A) by amending paragraph (1) to read as 

5 follows: 

6 ‘‘(1) IN GENERAL.—To carry out this section, 

7 there are appropriated such sums as may be nec8 essary, not to exceed— 

9 ‘‘(A) $230,000,000, for the period of fiscal 

10 years 2011 through 2015; 

11 ‘‘(B) $60,000,000 for each of fiscal years 

12 2016 and 2017; 

13 ‘‘(C) $126,500,000 for each of fiscal years 

14 2018 through 2023; 

15 ‘‘(D) $175,000,000 for each of fiscal years 

16 2024 and 2025; 

17 ‘‘(E) $225,000,000 for each of fiscal years 

18 2026 and 2027; and 

19 ‘‘(F) $300,000,000 for each of fiscal years 

20 2028, 2029, and 2030.’’; and 

21 (B) by adding at the end the following: 

22 ‘‘(3) AVAILABILITY.—The amounts made avail23 able under paragraph (1) shall remain available until 

24 expended.’’. 


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1 (b) EXTENSION FOR COMMUNITY HEALTH CEN2 TERS.—Section 10503(b)(1)(F) of the Patient Protection 

3 and Affordable Care Act (42 U.S.C. 254b–2(b)(1)(F)) is 

4 amended— 

5 (1) by striking ‘‘and’’ before ‘‘$4,000,000,000’’ 

6 and inserting a comma; and 

7 (2) by inserting ‘‘, $4,400,000,000 for each of 

8 fiscal years 2024 and 2025, and $1,109,000,000 for 

9 the period beginning October 1, 2025, and ending 

10 December 31, 2025’’ before the semicolon. 

11 (c) EXTENSION FOR THE NATIONAL HEALTH SERV12 ICE CORPS.—Section 10503(b)(2) of the Patient Protec13 tion and Affordable Care Act (42 U.S.C. 254b–2(b)(2)) 

14 is amended— 

15 (1) in subparagraph (G), by striking ‘‘and’’ at 

16 the end; 

17 (2) in subparagraph (H), by striking the period 

18 at the end and inserting ‘‘; and’’; and 

19 (3) by adding at the end the following: 

20 ‘‘(I) $350,000,000 for each of fiscal years 

21 2024 and 2025, and $88,219,178 for the period 

22 beginning October 1, 2025, and ending Decem23 ber 31, 2025.’’. 

24 (d) GOVERNMENT ACCOUNTABILITY OFFICE RE25 PORT.— 


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1 (1) IN GENERAL.—Not later than one year 

2 after the date of enactment of this Act, the Comp3 troller General of the United States shall submit to 

4 the Committee on Energy and Commerce of the 

5 House of Representatives and the Committee on 

6 Health, Education, Labor, and Pensions of the Sen7 ate a report assessing the effectiveness of the Na8 tional Health Service Corps at attracting health care 

9 professionals to HPSAs, including by— 

10 (A) assessing the metrics used by the 

11 Health Resources and Services Administration 

12 in evaluating the program; 

13 (B) comparing the retention rates of 

14 NHSC participants in the HPSAs where they 

15 completed their period of obligated service to 

16 the retention rate of non-NHSC participants in 

17 the corresponding HPSAs; 

18 (C) comparing the retention rates of 

19 NHSC participants in the HPSAs where they 

20 completed their period of obligated service to 

21 the retention rates of NHSC participants in 

22 HPSAs other than those where they completed 

23 their period of obligated service; 

24 (D) identifying factors that influence a 

25 NHSC participant’s decision to practice in a 


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1 HPSA other than the HPSA where they com2 pleted their period of obligated service; 

3 (E) identifying factors other than partici4 pation in the National Health Service Corps 

5 Scholarship and Loan Repayment Programs 

6 that attract health care professionals to a 

7 HPSA; 

8 (F) assessing the impact the National 

9 Health Service Corps has on wages for health 

10 care professionals in a HPSA; and 

11 (G) comparing the distribution of NHSC 

12 participants across HPSAs, including a com13 parison of rural versus non-rural HPSAs. 

14 (2) DEFINITION.—In this section: 

15 (A) The term ‘‘HPSA’’ means a health 

16 professional shortage area designated under 

17 section 332 of the Public Health Service Act 

18 (42 U.S.C. 254e). 

19 (B) The term ‘‘NHSC participant’’ means 

20 a National Health Service Corps member par21 ticipating in the National Health Service Corps 

22 Scholarship or Loan Repayment Program. 

23 (e) APPLICATION OF PROVISIONS.—Amounts appro24 priated pursuant to the amendments made by this section 

25 shall be subject to the requirements contained in Public 


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1 Law 117–328 for funds for programs authorized under 

2 sections 330 through 340 of the Public Health Service 

3 Act. 

4 (f) CONFORMING AMENDMENT.—Paragraph (4) of 

5 section 3014(h) of title 18, United States Code, is amend6 ed by striking ‘‘and section 301(d) of division BB of the 

7 Consolidated Appropriations Act, 2021.’’ and inserting 

8 ‘‘section 301(d) of division BB of the Consolidated Appro9 priations Act, 2021, and section 301(e) of the Lower 

10 Costs, More Transparency Act.’’. 

11 SEC. 302. EXTENSION OF SPECIAL DIABETES PROGRAMS. 

12 (a) EXTENSION OF SPECIAL DIABETES PROGRAMS

13 FOR TYPE I DIABETES.—Section 330B(b)(2) of the Pub14 lic Health Service Act (42 U.S.C. 254c–2(b)(2)) is amend15 ed— 

16 (1) in subparagraph (C), by striking ‘‘and’’ at 

17 the end; 

18 (2) in subparagraph (D), by striking the period 

19 at the end and inserting a semicolon; and 

20 (3) by adding at the end the following: 

21 ‘‘(E) $170,000,000 for each of fiscal years 

22 2024 and 2025, to remain available until ex23 pended; and 


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1 ‘‘(F) $42,849,315 for the period beginning 

2 October 1, 2025, and ending December 31, 

3 2025, to remain available until expended.’’. 

4 (b) EXTENDING FUNDING FOR SPECIAL DIABETES

5 PROGRAMS FOR INDIANS.—Section 330C(c)(2) of the 

6 Public Health Service Act (42 U.S.C. 254c–3(c)(2)) is 

7 amended— 

8 (1) in subparagraph (C), by striking ‘‘and’’ at 

9 the end; 

10 (2) in subparagraph (D), by striking the period 

11 at the end and inserting a semicolon; and 

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

13 ‘‘(E) $170,000,000 for each of fiscal years 

14 2024 and 2025, to remain available until ex15 pended; and 

16 ‘‘(F) $42,849,315 for the period beginning 

17 October 1, 2025, and ending December 31, 

18 2025, to remain available until expended.’’. 

19 SEC. 303. DELAYING CERTAIN DISPROPORTIONATE SHARE 

20 HOSPITAL PAYMENT REDUCTIONS UNDER 

21 THE MEDICAID PROGRAM. 

22 Section 1923(f)(7)(A) of the Social Security Act (42 

23 U.S.C.1396r–4(f)(7)(A)) is amended— 


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1 (1) in clause (i), in the matter preceding sub2 clause (I), by striking ‘‘2024’’ and inserting ‘‘2026’’; 

3 and 

4 (2) in clause (ii), by striking ‘‘2024’’ and in5 serting ‘‘2026’’. 

6 SEC. 304. MEDICAID IMPROVEMENT FUND. 

7 Section 1941(b)(3)(A) of the Social Security Act (42 

8 U.S.C. 1396w–1(b)(3)(A)) is amended by striking 

9 ‘‘$7,000,000,000’’ and inserting ‘‘$0’’. 

10 TITLE IV—INCREASING ACCESS 

11 TO QUALITY HEALTH DATA 

12 AND LOWERING HIDDEN 

13 FEES 

14 SEC. 401. INCREASING PLAN FIDUCIARIES’ ACCESS TO 

15 HEALTH DATA. 

16 (a) PLAN FIDUCIARY ACCESS TO INFORMATION.— 

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

18 408(b) of the Employee Retirement Income Security 

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

20 adding at the end the following new subparagraph: 

21 ‘‘(C) No contract or arrangement for services 

22 between a group health plan and any other entity, 

23 including a health care provider (including a health 

24 care facility), network or association of providers, 

25 service provider offering access to a network of proVerDate Sep 11 2014 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00200 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 viders, third-party administrator, or pharmacy ben2 efit manager, is reasonable within the meaning of 

3 this paragraph unless such contract or arrange4 ment— 

5 ‘‘(i) allows the responsible plan fiduciary to 

6 audit or review all de-identified claims and en7 counter information or data described in section 

8 724(a)(1)(B) to— 

9 ‘‘(I) ensure that such entity complies 

10 with the terms of the plan and any appli11 cable law; and 

12 ‘‘(II) determine the reasonableness of 

13 compensation received by such entity; and 

14 ‘‘(ii) does not— 

15 ‘‘(I) unreasonably limit the number of 

16 audits permitted during a given period of 

17 time; 

18 ‘‘(II) limit the number of de-identified 

19 claims and encounter information or data 

20 that the responsible plan fiduciary may ac21 cess during an audit; 

22 ‘‘(III) limit the disclosure of pricing 

23 terms for value-based payment arrange24 ments or capitated payment arrangements, 

25 including— 


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1 ‘‘(aa) payment calculations and 

2 formulas; 

3 ‘‘(bb) quality measures; 

4 ‘‘(cc) contract terms; 

5 ‘‘(dd) payment amounts; 

6 ‘‘(ee) measurement periods for all 

7 incentives; and 

8 ‘‘(ff) other payment methodolo9 gies used by an entity, including a 

10 health care provider (including a 

11 health care facility), network or asso12 ciation of providers, service provider 

13 offering access to a network of pro14 viders, third-party administrator, or 

15 pharmacy benefit manager; 

16 ‘‘(IV) limit the disclosure of overpay17 ments and overpayment recovery terms; 

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

19 plan fiduciary to select an auditor; 

20 ‘‘(VI) otherwise limit or unduly delay 

21 by greater than 60 calendar days after the 

22 date of request the responsible plan fidu23 ciary from auditing all de-identified claims 

24 and encounter information or data; or 


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1 ‘‘(VII) permit the entity to charge a 

2 fee beyond the reasonable direct costs to 

3 provide the required information and oth4 erwise comply and assist with an audit re5 quest. 

6 ‘‘(D) PRIVACY REQUIREMENTS.—Covered 

7 service providers shall provide information 

8 under this subparagraph in a manner consistent 

9 with the privacy, security, and breach notifica10 tion regulations promulgated under section 

11 13402(a) of the Health Information Technology 

12 for Clinical Health Act, and shall restrict the 

13 use and disclosure of such information accord14 ing to such privacy regulations. 

15 ‘‘(E) DISCLOSURE AND REDISCLOSURE.— 

16 ‘‘(i) LIMITATION TO BUSINESS ASSO17 CIATES.—A responsible plan fiduciary re18 ceiving a report under this subparagraph 

19 may disclose such information only to the 

20 entity from which the report was received, 

21 the group health plan for which the report 

22 pertains, or to that entity’s business asso23 ciates as defined in section 160.103 of title 

24 45, Code of Federal Regulations (or suc25 cessor regulations) or as permitted by the 


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1 HIPAA Privacy Rule (45 C.F.R. parts 160 

2 and 164, subparts A and E). 

3 ‘‘(ii) CLARIFICATION REGARDING PUB4 LIC DISCLOSURE OF INFORMATION.—Noth5 ing in this section shall prevent a group 

6 health plan or health insurance issuer of7 fering group health insurance coverage, or 

8 a covered service provider, from placing 

9 reasonable restrictions on the public disclo10 sure of the information contained in a re11 port described in this subparagraph, except 

12 that such plan, issuer, or entity may not 

13 restrict disclosure of such report to the De14 partment of Labor.’’. 

15 (2) CIVIL ENFORCEMENT.— 

16 (A) IN GENERAL.—Subsection (c) of sec17 tion 502 of such Act (29 U.S.C. 1132) is 

18 amended by adding at the end the following 

19 new paragraph: 

20 ‘‘(13) In the case of an agreement between a group 

21 health plan and a health care provider (including a health 

22 care facility), network or association of providers, service 

23 provider offering access to a network of providers, third24 party administrator, or pharmacy benefit manager, that 

25 violates the provisions of section 724, the Secretary may 


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1 assess a civil penalty against such provider, network or 

2 association, service provider offering access to a network 

3 of providers, third-party administrator, pharmacy benefit 

4 manager, or other service provider in the amount of 

5 $10,000 for each day during which such violation con6 tinues. Such penalty shall be in addition to other penalties 

7 as may be prescribed by law.’’. 

8 (B) CONFORMING AMENDMENT.—Para9 graph (6) of section 502(a) of such Act is 

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

11 ‘‘(9), or (13)’’. 

12 (3) EXISTING PROVISIONS VOID.—Section 410 

13 of such Act is amended by adding at the end the fol14 lowing new subsection: 

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

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

17 ‘‘(1) unduly delays or limits a plan fiduciary 

18 from accessing the de-identified claims and encoun19 ter information or data described in section 

20 724(a)(1)(B); or 

21 ‘‘(2) violates the requirements of section 

22 408(b)(2)(C).’’. 

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

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


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1 striking ‘‘this clause’’ and inserting ‘‘this para2 graph’’. 

3 (b) UPDATED ATTESTATION FOR PRICE AND QUAL4 ITY INFORMATION.—Section 724(a)(3) of the Employee 

5 Retirement Income Security Act (29 U.S.C. 1185m(a)(3)) 

6 is amended to read as follows: 

7 ‘‘(3) ATTESTATION.— 

8 ‘‘(A) IN GENERAL.—Subject to subpara9 graph (C), the plan fiduciary of a group health 

10 plan or health insurance issuer offering group 

11 health insurance coverage shall annually submit 

12 to the Secretary an attestation that such plan 

13 or issuer of such coverage is in compliance with 

14 the requirements of this subsection. Such attes15 tation shall also include a statement verifying 

16 that— 

17 ‘‘(i) the information or data described 

18 under subparagraphs (A) and (B) of para19 graph (1) is available upon request and 

20 provided to the plan fiduciary, the plan ad21 ministrator, or the issuer in a timely man22 ner; and 

23 ‘‘(ii) there are no terms in the agree24 ment under such paragraph (1) that di25 rectly or indirectly restrict or unduly delay 


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1 a plan fiduciary, the plan administrator, or 

2 the issuer from auditing, reviewing, or oth3 erwise accessing such information, except 

4 as permitted under section 408(b)(2)(C). 

5 ‘‘(B) LIMITATION ON SUBMISSION.—Sub6 ject to clause (ii), a group health plan or issuer 

7 offering group health insurance coverage may 

8 not enter into an agreement with a third-party 

9 administrator or other service provider to sub10 mit the attestation required under subpara11 graph (A). 

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

13 health plan or issuer offering group health in14 surance coverage that is unable to obtain the 

15 information or data needed to submit the attes16 tation required under subparagraph (A), such 

17 plan or issuer may submit a written statement 

18 in lieu of such attestation that includes— 

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

20 or issuer was unsuccessful in obtaining 

21 such information or data, including wheth22 er such plan or issuer was limited or pre23 vented from auditing, reviewing, or other24 wise accessing such information or data; 


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

2 by the plan fiduciary to remove any gag 

3 clause provisions from the agreement 

4 under paragraph (1); and 

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

6 the third-party administrator or other serv7 ice provider with respect to efforts to com8 ply with the attestation requirement under 

9 subparagraph (A).’’. 

10 (c) REPORT ON PLAN ASSETS.—Not later than 1 

11 year after the date of enactment of this Act, the Secretary 

12 of Labor shall submit to the Committee on Education and 

13 the Workforce of the House of Representatives a report 

14 on the status of de-identified claims and encounter infor15 mation or data described in section 724(a)(1)(B) of the 

16 Employee Retirement Income Security Act of 1974 (29 

17 U.S.C. 1185m), including information on the following: 

18 (1) Whether changes to regulations or guidance 

19 would permit such information or data to be deemed 

20 a group health plan asset (as defined under section 

21 3(42) of such Act). 

22 (2) Whether restrictions on the ability of a plan 

23 fiduciary to access such information or data violates 

24 a requirement of current law. 


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1 (3) The existing regulatory authority of the 

2 Secretary to clarify whether such information or 

3 data is the property of a group health plan, rather 

4 than a service provider. 

5 (4) Legislative actions that may be taken to es6 tablish that such information or data related to a 

7 plan belongs to a group health plan and is handled 

8 in the best interests of plan participants and bene9 ficiaries. 

10 (d) EFFECTIVE DATE.—The amendments made by 

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

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

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

14 Act. 

15 SEC. 402. HIDDEN FEES DISCLOSURE REQUIREMENTS . 

16 (a) CLARIFICATION OF THE APPLICATION OF FEE

17 DISCLOSURE REQUIREMENTS TO COVERED SERVICE PRO18 VIDERS.— 

19 (1) SERVICES.—Clause (ii)(I)(bb) of section 

20 408(b)(2)(B) of the Employee Retirement Income 

21 Security Act of 1974 (29 U.S.C. 1108(b)(2)(B)) is 

22 amended— 

23 (A) in subitem (AA) by striking ‘‘Broker24 age services,’’ and inserting ‘‘Services (includ25 ing brokerage services),’’; and 


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1 (B) in subitem (BB)— 

2 (i) by striking ‘‘Consulting,’’ and in3 serting ‘‘Other services,’’; and 

4 (ii) by inserting ‘‘any of the fol5 lowing:’’ before ‘‘plan design’’. 

6 (2) DISCLOSURES.—Clause (iii)(III) of section 

7 408(b)(2)(B) of the Employee Retirement Income 

8 Security Act of 1974 (29 U.S.C. 1108(b)(2)(B)) is 

9 amended by striking ‘‘, either in the aggregate or by 

10 service,’’ and inserting ‘‘by service’’. 

11 (b) STRENGTHENING DISCLOSURE REQUIREMENTS

12 WITH RESPECT TO PHARMACY BENEFIT MANAGERS AND

13 THIRD PARTY ADMINISTRATORS FOR GROUP HEALTH

14 PLANS.— 

15 (1) CERTAIN ARRANGEMENTS FOR PBM SERV16 ICES CONSIDERED AS INDIRECT.— 

17 (A) IN GENERAL.—Clause (i) of section 

18 408(b)(2)(B) of the Employee Retirement In19 come Security Act of 1974 (29 U.S.C. 

20 1108(b)(2)(B)) is amended— 

21 (i) by striking ‘‘requirements of this 

22 clause’’ and inserting ‘‘requirements of this 

23 subparagraph’’; and 

24 (ii) by adding at the end the fol25 lowing: ‘‘For purposes of applying section 


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1 406(a)(1)(C) with respect to a transaction 

2 described under this subparagraph, a con3 tract or arrangement for services between 

4 a covered plan and a health insurance 

5 issuer providing health insurance coverage 

6 in connection with the covered plan in 

7 which the health insurance issuer con8 tracts, in connection with such plan, with 

9 a service provider for pharmacy benefit 

10 management services shall be considered to 

11 constitute an indirect furnishing of goods, 

12 services, or facilities between the plan and 

13 the service provider acting as the party in 

14 interest.’’. 

15 (B) HEALTH INSURANCE ISSUER AND

16 HEALTH INSURANCE COVERAGE DEFINED.— 

17 Clause (ii)(I)(aa) of section 408(b)(2)(B) of 

18 such Act (29 U.S.C. 1108(b)(2)(B)) is amended 

19 by inserting before the period at the end ‘‘and 

20 the terms ‘health insurance coverage’ and 

21 ‘health insurance issuer’ have the meanings 

22 given such terms in section 733(b)’’. 

23 (C) TECHNICAL AMENDMENT.—Clause 

24 (ii)(I)(aa) of section 408(b)(2)(B) of the Em25 ployee Retirement Income Security Act of 1974 


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1 (29 U.S.C. 1108(b)(2)(B)) is further amended 

2 by inserting ‘‘in’’ after ‘‘defined’’. 

3 (2) SPECIFIC DISCLOSURE REQUIREMENTS

4 WITH RESPECT TO PHARMACY BENEFIT MANAGE5 MENT SERVICES.— 

6 (A) IN GENERAL.—Clause (iii) of section 

7 408(b)(2)(B) of such Act (29 U.S.C. 

8 1108(b)(2)(B)) is amended by adding at the 

9 end the following: 

10 ‘‘(VII) With respect to a contract or ar11 rangement with the covered plan in connection 

12 with the provision of pharmacy benefit manage13 ment services, as part of the description re14 quired under subclauses (III) and (IV)— 

15 ‘‘(aa) all compensation described in 

16 clause (ii)(I)(dd)(AA), including fees, re17 bates, alternative discounts, co-payment 

18 offsets, and other remuneration expected 

19 to be received by the covered service pro20 vider, an affiliate, or a subcontractor from 

21 a pharmaceutical manufacturer, dis22 tributor, rebate aggregator, accumulator, 

23 and maximizer, group purchasing organiza24 tion, or any other third party; 


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1 ‘‘(bb) the amount and form of any re2 bates, discounts, or price concessions, in3 cluding the amount expected to be passed 

4 through to the plan sponsor or the partici5 pants and beneficiaries under the covered 

6 plan; 

7 ‘‘(cc) all compensation expected to be 

8 received by the covered service provider, an 

9 affiliate, or a subcontractor as a result of 

10 paying a lower amount for the drug than 

11 the amount charged as a copayment, coin12 surance amount, or deductible; 

13 ‘‘(dd) all compensation expected to be 

14 received by the covered service provider, an 

15 affiliate, or a subcontractor as a result of 

16 paying pharmacies less than what is 

17 charged the health plan, plan sponsor, or 

18 participants and beneficiaries under the 

19 covered plan; and 

20 ‘‘(ee) all compensation expected to be 

21 received by the covered service provider, an 

22 affiliate, or a subcontractor from drug 

23 manufacturers and any other third party 

24 in exchange for— 


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1 ‘‘(AA) administering, invoicing, 

2 allocating, or collecting rebates related 

3 to the covered plan; 

4 ‘‘(BB) providing business serv5 ices and activities, including providing 

6 access to drug utilization data; 

7 ‘‘(CC) keeping a percentage of 

8 the list price of a drug; or 

9 ‘‘(DD) any other reason related 

10 to the role of a covered service pro11 vider as a conduit between the drug 

12 manufacturers or any other third 

13 party and the covered plan.’’. 

14 (B) ANNUAL DISCLOSURE.—Clause (v) of 

15 section 408(b)(2)(B) of such Act (29 U.S.C. 

16 1108(b)(2)(B)) is amended by adding at the 

17 end the following: 

18 ‘‘(III) A covered service provider, with re19 spect to a contract or arrangement with the 

20 covered plan in connection with providing phar21 macy benefit management services, shall dis22 close, on an annual basis not later than 60 days 

23 after the beginning of the current plan year, to 

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1 lowing with respect to the twelve months pre2 ceding the current plan year: 

3 ‘‘(aa) All direct compensation de4 scribed in subclause (III) of clause (iii) 

5 and indirect compensation described in 

6 subclause (IV) of clause (iii) received by 

7 the covered service provider (including 

8 such compensation described in subclause 

9 (VII) of clause (iii)). 

10 ‘‘(bb) For each drug covered under 

11 the covered plan, the amount by which the 

12 price for the drug paid by the plan exceeds 

13 the amount paid to pharmacies by the cov14 ered service provider. 

15 ‘‘(cc) The total gross spending by the 

16 covered plan on drugs (excluding rebates, 

17 discounts, or other price concessions). 

18 ‘‘(dd) The total net spending by the 

19 covered plan on drugs. 

20 ‘‘(ee) The total gross spending at all 

21 pharmacies wholly or partially owned by 

22 the covered service provider or any entity 

23 affiliated with the covered service provider, 

24 including mail-order, specialty and retail 


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1 pharmacies, with a breakdown by indi2 vidual pharmacy location. 

3 ‘‘(ff) The aggregate amount of 

4 clawback from such pharmacies, including 

5 mail-order, specialty, and retail phar6 macies. 

7 ‘‘(AA) categorical explanations 

8 (grouped by the reason for clawback, 

9 such as contractual true-up provi10 sions, overpayments, or non-covered 

11 medication dispensed, and including 

12 information on the amount in each 

13 category that was passed through to 

14 the covered plan and to participants 

15 and beneficiaries of the covered plan); 

16 or 

17 ‘‘(BB) individual explanations for 

18 such clawbacks. 

19 ‘‘(gg) Total aggregate amounts of fees 

20 collected by the covered service provider, 

21 an affiliate, or a subcontractor in connec22 tion with the provision of pharmacy benefit 

23 management services to the covered plan. 

24 ‘‘(hh) Any other information specified 

25 by the Secretary through regulations or 


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1 guidance that may be necessary for a re2 sponsible plan fiduciary to consider the 

3 merits of the contract or arrangement with 

4 the covered service provider and any con5 flicts of interest that may exist.’’. 

6 (C) PHARMACY BENEFIT MANAGEMENT

7 SERVICES DEFINED.—Clause (ii)(I) of section 

8 408(b)(2)(B) of such Act (29 U.S.C. 

9 1108(b)(2)(B)) is amended by adding at the 

10 end the following: 

11 ‘‘(gg) The term ‘pharmacy benefit 

12 management services’ includes any services 

13 provided by a covered service provider to a 

14 covered plan with respect to the adminis15 tration of prescription drug benefits under 

16 the covered plan, including— 

17 ‘‘(AA) the processing and pay18 ment of claims; 

19 ‘‘(BB) design of pharmacy net20 works; 

21 ‘‘(CC) negotiation, aggregation, 

22 and distribution of rebates, discounts, 

23 and other price concessions; 

24 ‘‘(DD) formulary design and 

25 maintenance; 


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1 ‘‘(EE) operation of pharmacies 

2 (whether retail, mail order, specialty 

3 drug, or otherwise); 

4 ‘‘(FF) recordkeeping; 

5 ‘‘(GG) utilization review; 

6 ‘‘(HH) adjudication of claims; 

7 and 

8 ‘‘(II) any other services specified 

9 by the Secretary through guidance or 

10 rulemaking.’’. 

11 (D) CLAWBACK DEFINED.—Clause (ii)(I) 

12 of section 408(b)(2)(B) of such Act (29 U.S.C. 

13 1108(b)(2)(B)), as amended by subparagraph 

14 (C), is amended by adding at the end the fol15 lowing: 

16 ‘‘(hh) The term ‘clawback’ means 

17 amounts collected by a provider of phar18 macy benefit management services from a 

19 pharmacy for copayments collected from a 

20 participant or beneficiary in excess of the 

21 contracted rate.’’. 

22 (3) SPECIFIC DISCLOSURE REQUIREMENTS

23 WITH RESPECT TO THIRD PARTY ADMINISTRATION

24 SERVICES FOR GROUP HEALTH PLANS.— 


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1 (A) IN GENERAL.—Clause (iii) of section 

2 408(b)(2)(B) of such Act (29 U.S.C. 

3 1108(b)(2)(B)), as amended by paragraph 

4 (2)(A), is amended by adding at the end the 

5 following: 

6 ‘‘(VIII) With respect to a contract or ar7 rangement with the covered plan in connection 

8 with the provision of third party administration 

9 services for group health plans, as part of the 

10 description required under subclauses (III) and 

11 (IV)— 

12 ‘‘(aa) the amount and form of any re13 bates, discounts, savings fees, refunds, or 

14 amounts received from providers and facili15 ties, including the amounts that will be re16 tained by the covered service provider as a 

17 fee; 

18 ‘‘(bb) the amount and form of fees ex19 pected to be received from other service 

20 providers in relation to the covered plan, 

21 including the amounts that will be retained 

22 by the covered service provider as a fee; 

23 and 

24 ‘‘(cc) the amount and form of ex25 pected recoveries by the covered service 


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1 provider, including the amounts that will 

2 be retained by the covered service provider 

3 as a fee (disaggregated by category), as a 

4 result of— 

5 ‘‘(AA) overpayments; 

6 ‘‘(BB) erroneous payments; 

7 ‘‘(CC) uncashed checks or incom8 plete payments; 

9 ‘‘(DD) billing errors; 

10 ‘‘(EE) subrogation; 

11 ‘‘(FF) fraud; or 

12 ‘‘(GG) any other reason on behalf 

13 of the covered plan.’’. 

14 (B) ANNUAL DISCLOSURE.—Clause (v) of 

15 section 408(b)(2)(B) of such Act (29 U.S.C. 

16 1108(b)(2)(B)), as amended by paragraph 

17 (2)(B), is amended by adding at the end the 

18 following: 

19 ‘‘(IV) A covered service provider, with re20 spect to a contract or arrangement with the 

21 covered plan in connection with providing third 

22 party administration services for group health 

23 plans, shall disclose, on an annual basis not 

24 later than 60 days after the beginning of the 

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1 ciary, in writing, the following with respect to 

2 the twelve months preceding the current plan 

3 year: 

4 ‘‘(aa) All direct compensation de5 scribed in subclause (III) of clause (iii). 

6 ‘‘(bb) All indirect compensation de7 scribed in subclause (IV) of clause (iii) re8 ceived by the covered service provider, an 

9 affiliate, or a subcontractor (including such 

10 compensation described in subclause (VIII) 

11 of clause (iii)). 

12 ‘‘(cc) The aggregate amount for which 

13 the covered service provider, an affiliate, or 

14 a subcontractor received indirect com15 pensation and the estimated amount of 

16 cost-sharing incurred by plan participants 

17 and beneficiaries as a result. 

18 ‘‘(dd) The total gross spending by the 

19 covered plan on all costs and fees arising 

20 under or paid under the administrative 

21 services agreement with the covered service 

22 provider (not including any amounts de23 scribed in items (aa) through (cc) of clause 

24 (iii)(VIII)). 


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1 ‘‘(ee) The total net spending by the 

2 covered plan on all costs and fees arising 

3 under or paid under the administrative 

4 services agreement with the covered service 

5 provider. 

6 ‘‘(ff) The aggregate fees collected by 

7 the covered service provider, an affiliate, or 

8 a subcontractor. 

9 ‘‘(gg) Any other information specified 

10 by the Secretary through regulations or 

11 guidance that may be necessary for a re12 sponsible plan fiduciary to consider the 

13 merits of the contract or arrangement with 

14 the covered service provider and any con15 flicts of interest that may exist.’’. 

16 (C) THIRD PARTY ADMINISTRATION SERV17 ICES FOR GROUP HEALTH PLANS DEFINED.— 

18 Clause (ii)(I) of section 408(b)(2)(B) of such 

19 Act (29 U.S.C. 1108(b)(2)(B)), as amended by 

20 paragraph (2)(C), is amended by adding at the 

21 end the following: 

22 ‘‘(ii) The term ‘third party adminis23 tration services for group health plans’ in24 cludes any services provided by a covered 

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1 tractor to a covered plan with respect to 

2 the administration of health benefits under 

3 the covered plan, including— 

4 ‘‘(AA) the processing, repricing, 

5 and payment of claims; 

6 ‘‘(BB) design, creation, and 

7 maintenance of provider networks; 

8 ‘‘(CC) negotiation of discounts 

9 off gross rates; 

10 ‘‘(DD) benefit and plan design; 

11 ‘‘(EE) negotiation of payment 

12 rates; 

13 ‘‘(FF) recordkeeping; 

14 ‘‘(GG) utilization review; 

15 ‘‘(HH) adjudication of claims; 

16 ‘‘(II) regulatory compliance; and 

17 ‘‘(JJ) any other services set forth 

18 in an administrative services agree19 ment or similar agreement or specified 

20 by the Secretary through rule21 making.’’. 

22 (4) RULE OF CONSTRUCTION.—Nothing in the 

23 amendments made by this section shall be construed 

24 to imply that a practice in relation to which a cov25 ered service provider is required to provide informaVerDate Sep 11 2014 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00223 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 tion as a result of such amendments is permissible 

2 under Federal law. 

3 (5) EFFECTIVE DATE.—No contract or ar4 rangement entered into prior to January 1, 2025, 

5 shall be subject to the requirements of subsection 

6 (b). 

7 (c) IMPLEMENTATION.—Not later than 1 year after 

8 the date of enactment of this Act, the Secretary of Labor 

9 shall issue notice and comment rulemaking as necessary 

10 to implement the provisions of this section. The Secretary 

11 shall ensure that such rulemaking— 

12 (1) accounts for the varied compensation prac13 tices of covered service providers (as defined under 

14 section 408(b)(2)(B); and 

15 (2) establishes standards for the disclosure of 

16 expected compensation by such covered service pro17 viders. 

18 SEC. 403. PRESCRIPTION DRUG PRICE INFORMATION RE19 QUIREMENT. 

20 (a) PHSA.— 

21 (1) IN GENERAL.—Part D of title XXVII of the 

22 Public Health Service Act, as amended by section 

23 106, is further amended by adding at the end the 

24 following new section: 


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1 ‘‘SEC. 2799A–12. INFORMATION ON PRESCRIPTION DRUGS. 

2 ‘‘(a) IN GENERAL.—A group health plan or a health 

3 insurance issuer offering group or individual health insur4 ance coverage shall— 

5 ‘‘(1) not restrict, directly or indirectly, any 

6 pharmacy that dispenses a prescription drug to an 

7 enrollee in the plan or coverage from informing (or 

8 penalize such pharmacy for informing) an enrollee of 

9 any differential between the enrollee’s out-of-pocket 

10 cost under the plan or coverage with respect to ac11 quisition of the drug and the amount an individual 

12 would pay for acquisition of the drug without using 

13 any group health plan or health insurance coverage; 

14 and 

15 ‘‘(2) ensure that any entity that provides phar16 macy benefits management services under a contract 

17 with any such health plan or health insurance cov18 erage does not, with respect to such plan or cov19 erage, restrict, directly or indirectly, a pharmacy 

20 that dispenses a prescription drug from informing 

21 (or penalize such pharmacy for informing) an en22 rollee of any differential between the enrollee’s out23 of-pocket cost under such plan or coverage with re24 spect to acquisition of the drug and the amount an 

25 individual would pay for acquisition of the drug 


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1 without using any group health plan or health insur2 ance coverage. 

3 ‘‘(b) DEFINITION.—For purposes of this section, the 

4 term ‘out-of-pocket cost’, with respect to acquisition of a 

5 drug, means the amount to be paid by the enrollee under 

6 the plan or coverage, including any cost-sharing (including 

7 any deductible, copayment, or coinsurance) and, as deter8 mined by the Secretary, any other expenditure.’’. 

9 (2) CONFORMING AMENDMENT.—Section 2729 

10 of the Public Health Service Act (42 U.S.C. 300gg– 

11 29) is amended by adding at the end the following 

12 new subsection: 

13 ‘‘(c) SUNSET.—The preceding provisions of this sec14 tion shall not apply beginning on the date of the enact15 ment of this subsection.’’. 

16 (b) ERISA.— 

17 (1) IN GENERAL.—Subpart B of part 7 of Sub18 title B of title I of the Employee Retirement Income 

19 Security Act of 1974 (29 U.S.C. 1185 et seq.), as 

20 amended by section 106, is further amended by add21 ing at the end the following new section: 

22 ‘‘SEC. 727. INFORMATION ON PRESCRIPTION DRUGS. 

23 ‘‘(a) IN GENERAL.—A group health plan or a health 

24 insurance issuer offering group health insurance coverage 

25 shall— 


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1 ‘‘(1) not restrict, directly or indirectly, any 

2 pharmacy that dispenses a prescription drug to a 

3 participant or beneficiary in the plan or coverage 

4 from informing (or penalize such pharmacy for in5 forming) a participant or beneficiary of any differen6 tial between the participant’s or beneficiary’s out-of7 pocket cost under the plan or coverage with respect 

8 to acquisition of the drug and the amount an indi9 vidual would pay for acquisition of the drug without 

10 using any group health plan or health insurance cov11 erage; and 

12 ‘‘(2) ensure that any entity that provides phar13 macy benefits management services under a contract 

14 with any such health plan or health insurance cov15 erage does not, with respect to such plan or cov16 erage, restrict, directly or indirectly, a pharmacy 

17 that dispenses a prescription drug from informing 

18 (or penalize such pharmacy for informing) a partici19 pant or beneficiary of any differential between the 

20 participant’s or beneficiary’s out-of-pocket cost 

21 under such plan or coverage with respect to acquisi22 tion of the drug and the amount an individual would 

23 pay for acquisition of the drug without using any 

24 group health plan or health insurance coverage. 


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1 ‘‘(b) DEFINITION.—For purposes of this section, the 

2 term ‘out-of-pocket cost’, with respect to acquisition of a 

3 drug, means the amount to be paid by the participant or 

4 beneficiary under the plan or coverage, including any cost5 sharing (including any deductible, copayment, or coinsur6 ance) and, as determined by the Secretary, any other ex7 penditure.’’. 

8 (2) CLERICAL AMENDMENT.—The table of con9 tents in section 1 of the Employee Retirement In10 come Security Act of 1974 (29 U.S.C. 1001 et seq.), 

11 as amended by section 106, is further amended by 

12 inserting after the item relating to section 726 the 

13 following new item: 

‘‘Sec. 727. Information on prescription drugs.’’. 

14 (c) IRC.— 

15 (1) IN GENERAL.—Subchapter B of chapter 

16 100 of the Internal Revenue Code of 1986, as 

17 amended by section 106, is further amended by add18 ing at the end the following: 

19 ‘‘SEC. 9827. INFORMATION ON PRESCRIPTION DRUGS. 

20 ‘‘(a) IN GENERAL.—A group health plan shall— 

21 ‘‘(1) not restrict, directly or indirectly, any 

22 pharmacy that dispenses a prescription drug to a 

23 participant or beneficiary in the plan from informing 

24 (or penalize such pharmacy for informing) a partici25 pant or beneficiary of any differential between the 


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1 participant’s or beneficiary’s out-of-pocket cost 

2 under the plan with respect to acquisition of the 

3 drug and the amount an individual would pay for ac4 quisition of the drug without using any group health 

5 plan or health insurance coverage; and 

6 ‘‘(2) ensure that any entity that provides phar7 macy benefits management services under a contract 

8 with any such plan does not, with respect to such 

9 plan or coverage, restrict, directly or indirectly, a 

10 pharmacy that dispenses a prescription drug from 

11 informing (or penalize such pharmacy for informing) 

12 a participant or beneficiary of any differential be13 tween the participant’s or beneficiary’s out-of-pocket 

14 cost under the plan with respect to acquisition of the 

15 drug and the amount an individual would pay for ac16 quisition of the drug without using any group health 

17 plan or health insurance coverage. 

18 ‘‘(b) DEFINITION.—For purposes of this section, the 

19 term ‘out-of-pocket cost’, with respect to acquisition of a 

20 drug, means the amount to be paid by the participant or 

21 beneficiary under the plan, including any cost-sharing (in22 cluding any deductible, copayment, or coinsurance) and, 

23 as determined by the Secretary, any other expenditure.’’. 

24 (2) CLERICAL AMENDMENT.—The table of sec25 tions for subchapter B of chapter 100 of the InterVerDate Sep 11 2014 17:04 Sep 09, 2023 Jkt 039200 PO 00000 Frm 00229 Fmt 6652 Sfmt 6201 E:\BILLS\H5378.IH H5378

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1 nal Revenue Code of 1986, as amended by section 

2 106, is further amended by adding at the end the 

3 following new item: 

‘‘Sec. 9827. Information on prescription drugs.’’. 

4 SEC. 404. IMPLEMENTATION FUNDING. 

5 (a) IN GENERAL.—For the purposes described in 

6 subsection (b), and in addition to amounts otherwise avail7 able for such purposes there are appropriated, out of 

8 amounts in the Treasury not otherwise appropriated, to 

9 the Secretary of Labor $12,000,000, for fiscal year 2024, 

10 to remain available through fiscal year 2029. 

11 (b) PERMITTED PURPOSES.—The purposes described 

12 in this subsection are limited to the following purposes, 

13 insofar as such purposes are to carry out the provisions 

14 of, including the amendments made by, title I and IV: 

15 (1) Preparing, drafting, and issuing proposed 

16 and final regulations or interim regulations. 

17 (2) Preparing, drafting, and issuing guidance 

18 and public information. 

19 (3) Preparing, drafting, and publishing reports. 

20 (4) Enforcement of such provisions. 

21 (5) Reporting, collection, and analysis of data. 

22 (6) Other administrative duties necessary for 

23 implementation of such provisions. 

24 (c) TRANSPARENCY OF IMPLEMENTATION FUNDS.— 

25 The Secretary described in subsection (a) shall annually 


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1 submit, no later than September 1st of each year, to the 

2 Committees on Education and Workforce and on Appro3 priations of the House of Representatives and the Com4 mittees on Health, Education, Labor, and Pensions and 

5 on Appropriations of the Senate a report on funds ex6 pended pursuant to funds appropriated under this section. 

Æ 


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