118TH CONGRESS 

1ST SESSION H. R. 5378 

AN ACT 

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, 
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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Lower Costs, More 

3 Transparency Act’’. 

4 SEC. 2. TABLE OF CONTENTS. 

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

Sec. 1. Short title. 

Sec. 2. Table of contents. 

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 payment cuts. 

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. 
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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: 

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

8 ‘‘(a) TRANSPARENCY REQUIREMENT.— 

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

10 2026, each specified hospital that receives payment 

11 under this title for furnishing items and services 

12 shall comply with the price transparency require13 ment described in paragraph (2). 

14 ‘‘(2) REQUIREMENT DESCRIBED.— 

15 ‘‘(A) IN GENERAL.—For purposes of para16 graph (1), the price transparency requirement 

17 described in this paragraph is, with respect to 

18 a specified hospital, that such hospital, in ac19 cordance with a method and format established 

20 by the Secretary under subparagraph (C), com21 pile and make public (without subscription and 

22 free of charge) for each year— 

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

24 charges (including the information de-
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1 scribed in subparagraph (B)) for each item 

2 and service furnished by such hospital; 

3 ‘‘(ii) information in a consumer4 friendly format (as specified by the Sec5 retary)— 

6 ‘‘(I) on the hospital’s prices (in7 cluding the information described in 

8 subparagraph (B)) for as many of the 

9 Centers for Medicare & Medicaid 

10 Services-specified shoppable services 

11 that are furnished by the hospital, 

12 and as many additional hospital-se13 lected shoppable services (or all such 

14 additional services, if such hospital 

15 furnishes fewer than 300 shoppable 

16 services) as may be necessary for a 

17 combined total of at least 300 

18 shoppable services; and 

19 ‘‘(II) that includes, with respect 

20 to each Centers for Medicare & Med21 icaid Services-specified shoppable 

22 service that is not furnished by the 

23 hospital, an indication that such serv24 ice is not so furnished; and 
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1 ‘‘(iii) an attestation that all informa2 tion made public pursuant to this subpara3 graph is complete and accurate. 

4 ‘‘(B) INFORMATION DESCRIBED.—For pur5 poses of subparagraph (A), the information de6 scribed in this subparagraph is, with respect to 

7 standard charges and prices, as applicable, 

8 made public by a specified hospital, the fol9 lowing: 

10 ‘‘(i) A plain language description of 

11 each item or service, accompanied by, as 

12 applicable, the Healthcare Common Proce13 dure Coding System code, the diagnosis-re14 lated group, the national drug code, or 

15 other identifier used or approved by the 

16 Centers for Medicare & Medicaid Services. 

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

18 expressed as a dollar amount, for each 

19 such item or service, when provided in, as 

20 applicable, the inpatient setting and out21 patient department setting. 

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

23 applicable, expressed as a dollar amount, 

24 for each such item or service when pro25 vided in, as applicable, the inpatient set-
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1 ting and outpatient department setting (or, 

2 in the case no discounted cash price is 

3 available for an item or service, the median 

4 cash price charged by the hospital to self5 pay individuals for such item or service 

6 when provided in such settings for the pre7 vious three years, expressed as a dollar 

8 amount, as well as, with respect to prices 

9 made public pursuant to subparagraph 

10 (A)(ii), a link to a consumer-friendly docu11 ment that clearly explains the hospital’s 

12 charity care policy that includes, if applica13 ble, any sliding scale payment structure 

14 employed for determining charges for a 

15 self-pay individual). 

16 ‘‘(iv) The payer-specific negotiated 

17 charges, as applicable, clearly associated 

18 with the name of the third party payer and 

19 plan and expressed as a dollar amount, 

20 that apply to each such item or service 

21 when provided in, as applicable, the inpa22 tient setting and outpatient department 

23 setting. 
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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 In the case of standard charges and prices for 

13 an item or service included as part of a bun14 dled, per diem, episodic, or other similar ar15 rangement, the information described in this 

16 subparagraph shall be made available as deter17 mined appropriate by the Secretary. 

18 ‘‘(C) UNIFORM METHOD AND FORMAT.— 

19 Not later than January 1, 2026, the Secretary 

20 shall establish a standard, uniform method and 

21 format for specified hospitals to use in com22 piling and making public standard charges pur23 suant to subparagraph (A)(i) and a standard, 

24 uniform method and format for such hospitals 

25 to use in compiling and making public prices 
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1 pursuant to subparagraph (A)(ii). Such meth2 ods and formats— 

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

4 and format for making public standard 

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

6 ensure that such charges are made avail7 able in a machine-readable format (or a 

8 successor technology specified by the Sec9 retary); 

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

11 made available by the Centers for Medicare 

12 & Medicaid Services as of the date of the 

13 enactment of this subparagraph; 

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

16 order to ensure the accessibility and 

17 usability of such charges and prices; and 

18 ‘‘(iv) shall be updated as determined 

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

21 ‘‘(3) MONITORING COMPLIANCE.—The Sec22 retary shall, through notice and comment rule23 making and in consultation with the Inspector Gen24 eral of the Department of Health and Human Serv25 ices, establish a process to monitor compliance with 
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1 this subsection. Such process shall ensure that each 

2 specified hospital’s compliance with this subsection 

3 is reviewed not less frequently than once every 3 

4 years. 

5 ‘‘(4) ENFORCEMENT.— 

6 ‘‘(A) IN GENERAL.—In the case of a speci7 fied hospital that fails to comply with the re8 quirements of this subsection— 

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

10 date on which the Secretary determines 

11 such failure exists, the Secretary shall sub12 mit to such hospital a notification of such 

13 determination (which may include, as de14 termined appropriate by the Secretary, a 

15 request for a corrective action plan to com16 ply with such requirements); and 

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

18 does not receive a request for a corrective 

19 action plan as part of a notification sub20 mitted by the Secretary under clause (i)— 

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

22 than 45 days after such notification is 

23 sent, determine whether such hospital 

24 is in compliance with such require25 ments; and 
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1 ‘‘(II) if the Secretary determines 

2 under subclause (I) that such hospital 

3 is not in compliance with such re4 quirements, the Secretary shall ei5 ther— 

6 ‘‘(aa) submit to such hos7 pital a request for a corrective 

8 action plan to comply with such 

9 requirements; or 

10 ‘‘(bb) if the Secretary deter11 mines that such hospital has not 

12 taken meaningful actions to come 

13 into compliance since such notifi14 cation was sent, impose a civil 

15 monetary penalty in accordance 

16 with subparagraph (B). 

17 ‘‘(B) CIVIL MONETARY PENALTY.— 

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

19 (vii), in addition to any other enforcement 

20 actions or penalties that may apply under 

21 another provision of law, a specified hos22 pital that has received a request for a cor23 rective action plan under clause (i) or (ii) 

24 of subparagraph (A) and fails to comply 

25 with the requirements of this subsection by 
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1 the date that is 45 days after such request 

2 is made, and a specified hospital with re3 spect to which the Secretary has made a 

4 determination described in clause 

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

6 subject to a civil monetary penalty of an 

7 amount specified by the Secretary for each 

8 day (beginning with the day on which the 

9 Secretary first determined that such hos10 pital was not complying with such require11 ments) during which such failure was on12 going. Such amount shall not exceed— 

13 ‘‘(I) in the case of a specified 

14 hospital with 30 or fewer beds, $300 

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, $400 per 

20 day); 

21 ‘‘(II) in the case of a specified 

22 hospital with more than 30 beds but 

23 fewer than 101 beds, $12.50 per bed 

24 per day (or, in the case of such a hos25 pital that has been noncompliant with 
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1 such requirements for a 1-year period 

2 or longer, beginning with the first day 

3 following such 1-year period, $15 per 

4 bed per day); 

5 ‘‘(III) in the case of a specified 

6 hospital with more than 100 beds but 

7 fewer than 201 beds, $17.50 per bed 

8 per day (or, in the case of such a hos9 pital that has been noncompliant with 

10 such requirements for a 1-year period 

11 or longer, beginning with the first day 

12 following such 1-year period, $20 per 

13 bed per day); 

14 ‘‘(IV) in the case of a specified 

15 hospital with more than 200 beds but 

16 fewer than 501 beds, $20 per bed per 

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

18 that has been noncompliant with such 

19 requirements for a 1-year period or 

20 longer, beginning with the first day 

21 following such 1-year period, $25 per 

22 bed per day); and 

23 ‘‘(V) in the case of a specified 

24 hospital with more than 500 beds, 

25 $25 per bed per day (or, in the case 
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1 of such a hospital that has been non2 compliant with such requirements for 

3 a 1-year period or longer, beginning 

4 with the first day following such 1- 

5 year period, $35 per bed per 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— 

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

12 amount of any penalty applicable to a 

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

14 ‘‘(II) the limitations on the per 

15 bed per day amount of any penalty 

16 applicable under any of subclauses 

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

18 ‘‘(III) the amounts specified in 

19 clause (iii)(II). 

20 ‘‘(iii) PERSISTENT NONCOMPLI21 ANCE.— 

22 ‘‘(I) IN GENERAL.—In the case 

23 of a specified hospital (other than a 

24 specified hospital with 30 or fewer 

25 beds) that the Secretary has deter-
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1 mined to be knowingly and willfully 

2 noncompliant with the provisions of 

3 this subsection two or more times dur4 ing a 1-year period, the Secretary may 

5 increase any penalty otherwise appli6 cable under this subparagraph by the 

7 amount specified in subclause (II) 

8 with respect to such hospital and may 

9 require such hospital to complete such 

10 additional corrective actions plans as 

11 the Secretary may specify. 

12 ‘‘(II) SPECIFIED AMOUNT.—For 

13 purposes of subclause (I), the amount 

14 specified in this subclause is, with re15 spect to a specified hospital— 

16 ‘‘(aa) with more than 30 

17 beds but fewer than 101 beds, an 

18 amount that is not less than 

19 $500,000 and not more than 

20 $1,000,000; 

21 ‘‘(bb) with more than 100 

22 beds but fewer than 301 beds, an 

23 amount that is greater than 

24 $1,000,000 and not more than 

25 $2,000,000; 
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1 ‘‘(cc) with more than 300 

2 beds but fewer than 501 beds, an 

3 amount that is greater than 

4 $2,000,000 and not more than 

5 $4,000,000; and 

6 ‘‘(dd) with more than 500 

7 beds, and amount that is not less 

8 than $5,000,000 and not more 

9 than $10,000,000. 

10 ‘‘(iv) AUTHORITY TO WAIVE OR RE11 DUCE PENALTY.— 

12 ‘‘(I) IN GENERAL.—Subject to 

13 subclause (II), the Secretary may 

14 waive any penalty, or reduce any pen15 alty by not more than 75 percent, oth16 erwise applicable under this subpara17 graph with respect to a specified hos18 pital located in a rural or underserved 

19 area if the Secretary certifies that im20 position of such penalty would result 

21 in an immediate threat to access to 

22 care for individuals in the service area 

23 of such hospital. 

24 ‘‘(II) LIMITATION ON APPLICA25 TION.—The Secretary may not elect 
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1 to waive a penalty under subclause (I) 

2 with respect to a specified hospital 

3 more than once in a 6-year period and 

4 may not elect to reduce such a penalty 

5 with respect to such a hospital more 

6 than once in such a period. Nothing 

7 in the preceding sentence shall be con8 strued as prohibiting the Secretary 

9 from both waiving and reducing a 

10 penalty with respect to a specified 

11 hospital during a 6-year period. 

12 ‘‘(v) PROVISION OF TECHNICAL AS13 SISTANCE.—The Secretary shall, to the ex14 tent practicable, provide technical assist15 ance relating to compliance with the provi16 sions of this subsection to specified hos17 pitals requesting such assistance. 

18 ‘‘(vi) APPLICATION OF CERTAIN PRO19 VISIONS.—The provisions of section 1128A 

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

21 section) shall apply to a civil monetary 

22 penalty imposed under this subparagraph 

23 in the same manner as such provisions 

24 apply to a civil monetary penalty imposed 

25 under subsection (a) of such section. 
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1 ‘‘(vii) NONDUPLICATION OF CERTAIN

2 PENALTIES.—The Secretary may not sub3 ject a specified hospital to a civil monetary 

4 penalty under this subparagraph with re5 spect to noncompliance with the provisions 

6 of this section for a period if the Secretary 

7 has imposed a civil monetary penalty on 

8 such hospital under section 2718(f) of the 

9 Public Health Service Act for failure to 

10 comply with the provisions of such section 

11 for such period. 

12 ‘‘(C) PUBLICATION OF HOSPITAL PRICE

13 TRANSPARENCY INFORMATION.—Beginning on 

14 January 1, 2026, the Secretary shall make pub15 licly available on the public website of the Cen16 ters for Medicare & Medicaid Services informa17 tion with respect to compliance with the re18 quirements of this subsection and enforcement 

19 activities undertaken by the Secretary under 

20 this subsection. Such information shall be up21 dated in real time and include— 

22 ‘‘(i) the number of reviews of compli23 ance with this subsection undertaken by 

24 the Secretary; 
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1 ‘‘(ii) the number of notifications de2 scribed in subparagraph (A)(i) sent by the 

3 Secretary; 

4 ‘‘(iii) the identity of each specified 

5 hospital that was sent such a notification 

6 and a description of the nature of such 

7 hospital’s noncompliance with this sub8 section; 

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

10 penalty imposed on such hospital under 

11 subparagraph (B); 

12 ‘‘(v) whether such hospital subse13 quently came into compliance with this 

14 subsection; 

15 ‘‘(vi) any waivers or reductions of 

16 penalties made pursuant to a certification 

17 by the Secretary under subparagraph 

18 (B)(iv), including— 

19 ‘‘(I) the name of any specified 

20 hospital that received such a waiver or 

21 reduction; 

22 ‘‘(II) the dollar amount of each 

23 such penalty so waived or reduced; 

24 and 
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1 ‘‘(III) the rationale for the grant2 ing of each such waiver or reduction; 

3 and 

4 ‘‘(vii) any other information as deter5 mined by the Secretary. 

6 ‘‘(b) ENSURING ACCESSIBILITY THROUGH IMPLE7 MENTATION.—In implementing the amendments made by 

8 this section, the Secretary of Health and Human Services 

9 shall through rulemaking ensure that a hospital submit10 ting charges and information pursuant to such amend11 ments takes reasonable steps (as specified by the Sec12 retary) to ensure the accessibility of such charges and in13 formation to individuals with limited English proficiency. 

14 Such steps may include the hospital’s provision of inter15 pretation services or the hospital’s provision of trans16 lations of charges and information. 

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

18 ‘‘(1) DISCOUNTED CASH PRICE.—The term ‘dis19 counted cash price’ means the charge that applies to 

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

21 an item or service. 

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

23 term ‘Federal health care program’ has the meaning 

24 given such term in section 1128B. 
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1 ‘‘(3) GROSS CHARGE.—The term ‘gross charge’ 

2 means the charge for an individual item or service 

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

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

5 chargemaster, absent any discounts. 

6 ‘‘(4) GROUP HEALTH PLAN; GROUP HEALTH IN7 SURANCE COVERAGE; INDIVIDUAL HEALTH INSUR8 ANCE COVERAGE.—The terms ‘group health plan’, 

9 ‘group health insurance coverage’, and ‘individual 

10 health insurance coverage’ have the meaning given 

11 such terms in section 2791 of the Public Health 

12 Service Act. 

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

14 The term ‘payer-specific negotiated charge’ means 

15 the charge that a specified hospital or provider of 

16 services or supplier, as applicable, has negotiated 

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

18 ‘‘(6) SHOPPABLE SERVICE.—The term 

19 ‘shoppable service’ means a service that can be 

20 scheduled by a health care consumer in advance and 

21 includes all ancillary items and services customarily 

22 furnished as part of such service. 

23 ‘‘(7) SPECIFIED HOSPITAL.—The term ‘speci24 fied hospital’ means a hospital (as defined in section 

25 1861(e)), a critical access hospital (as defined in 
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1 section 1861(mmm)(1)), or a rural emergency hos2 pital (as defined in section 1861(kkk)). 

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

4 party payer’ means an entity that is, by statute, con5 tract, or agreement, legally responsible for payment 

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

7 (b) PHSA.— 

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

9 Health Service Act (42 U.S.C. 300gg–18) is amend10 ed by adding at the end the following new sub11 section: 

12 ‘‘(f) HOSPITAL TRANSPARENCY REQUIREMENT.— 

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

14 2026, each hospital shall comply with the price 

15 transparency requirement described in paragraph 

16 (2). 

17 ‘‘(2) REQUIREMENT DESCRIBED.— 

18 ‘‘(A) IN GENERAL.—For purposes of para19 graph (1), the price transparency requirement 

20 described in this paragraph is, with respect to 

21 a hospital, that such hospital, in accordance 

22 with a method and format established by the 

23 Secretary under subparagraph (C), compile and 

24 make public (without subscription and free of 

25 charge) for each year— 
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1 ‘‘(i) all of the hospital’s standard 

2 charges (including the information de3 scribed in subparagraph (B)) for each item 

4 and service furnished by such hospital; 

5 ‘‘(ii) information in a consumer6 friendly format (as specified by the Sec7 retary)— 

8 ‘‘(I) on the hospital’s prices (in9 cluding the information described in 

10 subparagraph (B)) for as many of the 

11 Centers for Medicare & Medicaid 

12 Services-specified shoppable services 

13 that are furnished by the hospital, 

14 and as many additional hospital-se15 lected shoppable services (or all such 

16 additional services, if such hospital 

17 furnishes fewer than 300 shoppable 

18 services) as may be necessary for a 

19 combined total of at least 300 

20 shoppable services; and 

21 ‘‘(II) that includes, with respect 

22 to each Centers for Medicare & Med23 icaid Services-specified shoppable 

24 service that is not furnished by the 
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1 hospital, an indication that such serv2 ice is not so furnished; and 

3 ‘‘(iii) an attestation that all informa4 tion made public pursuant to this subpara5 graph is complete and accurate. 

6 ‘‘(B) INFORMATION DESCRIBED.—For pur7 poses of subparagraph (A), the information de8 scribed in this subparagraph is, with respect to 

9 standard charges and prices, as applicable, 

10 made public by a hospital, the following: 

11 ‘‘(i) A plain language description of 

12 each item or service, accompanied by, as 

13 applicable, the Healthcare Common Proce14 dure Coding System code, the diagnosis-re15 lated group, the national drug code, cur16 rent procedure terminology codes, or other 

17 identifier used or approved by the Centers 

18 for Medicare & Medicaid Services. 

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

20 expressed as a dollar amount, for each 

21 such item or service, when provided in, as 

22 applicable, the inpatient setting and out23 patient department setting. 

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

25 applicable, expressed as a dollar amount, 
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1 for each such item or service when pro2 vided in, as applicable, the inpatient set3 ting and outpatient department setting (or, 

4 in the case no discounted cash price is 

5 available for an item or service, the median 

6 cash price charged by the hospital to self7 pay individuals for such item or service 

8 when provided in such settings for the pre9 vious three years, expressed as a dollar 

10 amount, as well as, with respect to prices 

11 made public pursuant to subparagraph 

12 (A)(ii), a link to a consumer-friendly docu13 ment that clearly explains the hospital’s 

14 charity care policy that includes, if applica15 ble, any sliding scale payment structure 

16 employed for determining charges for a 

17 self-pay individual). 

18 ‘‘(iv) The payer-specific negotiated 

19 charges, as applicable, clearly associated 

20 with the name of the third party payer and 

21 plan and expressed as a dollar amount, 

22 that apply to each such item or service 

23 when provided in, as applicable, the inpa24 tient setting and outpatient department 

25 setting. 
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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 In the case of standard charges and prices for 

13 an item or service included as part of a bun14 dled, per diem, episodic, or other similar ar15 rangement, the information described in this 

16 subparagraph shall be made available as deter17 mined appropriate by the Secretary. 

18 ‘‘(C) UNIFORM METHOD AND FORMAT.— 

19 Not later than January 1, 2026, the Secretary 

20 shall establish a standard, uniform method and 

21 format for hospitals to use in compiling and 

22 making public standard charges pursuant to 

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

24 method and format for such hospitals to use in 

25 compiling and making public prices pursuant to 
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1 subparagraph (A)(ii). Such methods and for2 mats— 

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

4 and format for making public standard 

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

6 ensure that such charges are made avail7 able in a machine-readable format (or a 

8 successor technology specified by the Sec9 retary); 

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

11 made available by the Centers for Medicare 

12 & Medicaid Services as of the date of the 

13 enactment of this subparagraph; 

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

16 order to ensure the accessibility and 

17 usability of such charges and prices; and 

18 ‘‘(iv) shall be updated as determined 

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

21 ‘‘(3) MONITORING COMPLIANCE.—The Sec22 retary shall, through notice and comment rule23 making and in consultation with the Inspector Gen24 eral of the Department of Health and Human Serv25 ices, establish a process to monitor compliance with 
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1 this subsection. Such process shall ensure that each 

2 hospital’s compliance with this subsection is re3 viewed not less frequently than once every 3 years. 

4 ‘‘(4) ENFORCEMENT.— 

5 ‘‘(A) IN GENERAL.—In the case of a hos6 pital that fails to comply with the requirements 

7 of this subsection— 

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

9 date on which the Secretary determines 

10 such failure exists, the Secretary shall sub11 mit to such hospital a notification of such 

12 determination (which may include, as de13 termined appropriate by the Secretary, a 

14 request for a corrective action plan to com15 ply with such requirements); and 

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

17 does not receive a request for a corrective 

18 action plan as part of a notification sub19 mitted by the Secretary under clause (i)— 

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

21 than 45 days after such notification is 

22 sent, determine whether such hospital 

23 is in compliance with such require24 ments; and 
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1 ‘‘(II) if the Secretary determines 

2 under subclause (I) that such hospital 

3 is not in compliance with such re4 quirements, the Secretary shall ei5 ther— 

6 ‘‘(aa) submit to such hos7 pital a request for a corrective 

8 action plan to comply with such 

9 requirements; or 

10 ‘‘(bb) if the Secretary deter11 mines that such hospital has not 

12 taken meaningful actions to come 

13 into compliance since such notifi14 cation was sent, impose a civil 

15 monetary penalty in accordance 

16 with subparagraph (B). 

17 ‘‘(B) CIVIL MONETARY PENALTY.— 

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

19 other enforcement actions or penalties that 

20 may apply under another provision of law, 

21 a hospital that has received a request for 

22 a corrective action plan under clause (i) or 

23 (ii) of subparagraph (A) and fails to com24 ply with the requirements of this sub25 section by the date that is 45 days after 
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1 such request is made, and a hospital with 

2 respect to which the Secretary has made a 

3 determination described in clause 

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

5 subject to a civil monetary penalty of an 

6 amount specified by the Secretary for each 

7 day (beginning with the day on which the 

8 Secretary first determined that such hos9 pital was not complying with such require10 ments) during which such failure was on11 going. Such amount shall not exceed— 

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

13 30 or fewer beds, $300 per day (or, in 

14 the case of such a hospital that has 

15 been noncompliant with such require16 ments for a 1-year period or longer, 

17 beginning with the first day following 

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

19 day); 

20 ‘‘(II) in the case of a hospital 

21 with more than 30 beds but fewer 

22 than 101 beds, $12.50 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 
30 

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1 longer, beginning with the first day 

2 following such 1-year period, $15 per 

3 bed per day); 

4 ‘‘(III) in the case of a hospital 

5 with more than 100 beds but fewer 

6 than 201 beds, $17.50 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, $20 per 

12 bed per day); 

13 ‘‘(IV) in the case of a hospital 

14 with more than 200 beds but fewer 

15 than 501 beds, $20 per bed per day 

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

17 has been noncompliant with such re18 quirements for a 1-year period or 

19 longer, beginning with the first day 

20 following such 1-year period, $25 per 

21 bed per day); and 

22 ‘‘(V) in the case of a hospital 

23 with more than 500 beds, $25 per bed 

24 per day (or, in the case of such a hos25 pital that has been noncompliant with 
31 

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1 such requirements for a 1-year period 

2 or longer, beginning with the first day 

3 following such 1-year period, $35 per 

4 bed per day). 

5 ‘‘(ii) INCREASE AUTHORITY.—In ap6 plying this subparagraph with respect to 

7 violations occurring in 2027 or a subse8 quent year, the Secretary may through no9 tice and comment rulemaking increase— 

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

11 amount of any penalty applicable to a 

12 hospital under clause (i)(I); 

13 ‘‘(II) the limitations on the per 

14 bed per day amount of any penalty 

15 applicable under any of subclauses 

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

17 ‘‘(III) the amounts specified in 

18 clause (iii)(II). 

19 ‘‘(iii) PERSISTENT NONCOMPLI20 ANCE.— 

21 ‘‘(I) IN GENERAL.—In the case 

22 of a hospital (other than a hospital 

23 with 30 or fewer beds) that the Sec24 retary has determined to be knowingly 

25 and willfully noncompliant with the 
32 

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1 provisions of this subsection two or 

2 more times during a 1-year period, 

3 the Secretary may increase any pen4 alty otherwise applicable under this 

5 subparagraph by the amount specified 

6 in subclause (II) with respect to such 

7 hospital and may require such hos8 pital to complete such additional cor9 rective actions plans as the Secretary 

10 may specify. 

11 ‘‘(II) SPECIFIED AMOUNT.—For 

12 purposes of subclause (I), the amount 

13 specified in this subclause is, with re14 spect to a hospital— 

15 ‘‘(aa) with more than 30 

16 beds but fewer than 101 beds, an 

17 amount that is not less than 

18 $500,000 and not more than 

19 $1,000,000; 

20 ‘‘(bb) with more than 100 

21 beds but fewer than 301 beds, an 

22 amount that is greater than 

23 $1,000,000 and not more than 

24 $2,000,000; 
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1 ‘‘(cc) with more than 300 

2 beds but fewer than 501 beds, an 

3 amount that is greater than 

4 $2,000,000 and not more than 

5 $4,000,000; and 

6 ‘‘(dd) with more than 500 

7 beds, and amount that is not less 

8 than $5,000,000 and not more 

9 than $10,000,000. 

10 ‘‘(iv) AUTHORITY TO WAIVE OR RE11 DUCE PENALTY.— 

12 ‘‘(I) IN GENERAL.—Subject to 

13 subclause (II), the Secretary may 

14 waive any penalty, or reduce any pen15 alty by not more than 75 percent, oth16 erwise applicable under this subpara17 graph with respect to a hospital lo18 cated in a rural or underserved area if 

19 the Secretary certifies that imposition 

20 of such penalty would result in an im21 mediate threat to access to care for 

22 individuals in the service area of such 

23 hospital. 

24 ‘‘(II) LIMITATION ON APPLICA25 TION.—The Secretary may not elect 
34 

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1 to waive a penalty under subclause (I) 

2 with respect to a hospital more than 

3 once in a 6-year period and may not 

4 elect to reduce such a penalty with re5 spect to such a hospital more than 

6 once in such a period. Nothing in the 

7 preceding sentence shall be construed 

8 as prohibiting the Secretary from both 

9 waiving and reducing a penalty with 

10 respect to a hospital during a 6-year 

11 period. 

12 ‘‘(v) PROVISION OF TECHNICAL AS13 SISTANCE.—The Secretary shall, to the ex14 tent practicable, provide technical assist15 ance relating to compliance with the provi16 sions of this section to hospitals requesting 

17 such assistance. 

18 ‘‘(vi) APPLICATION OF CERTAIN PRO19 VISIONS.—The provisions of section 1128A 

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

21 section) shall apply to a civil monetary 

22 penalty imposed under this subparagraph 

23 in the same manner as such provisions 

24 apply to a civil monetary penalty imposed 

25 under subsection (a) of such section. 
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1 ‘‘(vii) NONDUPLICATION OF PEN2 ALTIES.—The Secretary may not subject a 

3 hospital to a civil monetary penalty under 

4 this subparagraph with respect to non5 compliance with the provisions of this sub6 section for a period if the Secretary has 

7 imposed a civil monetary penalty on such 

8 hospital under section 1899C of the Social 

9 Security Act for failure to comply with the 

10 provisions of such section for such period. 

11 ‘‘(C) PUBLICATION OF HOSPITAL PRICE

12 TRANSPARENCY INFORMATION.—Beginning on 

13 January 1, 2026, the Secretary shall make pub14 licly available on the public website of the Cen15 ters for Medicare & Medicaid Services informa16 tion with respect to compliance with the re17 quirements of this subsection and enforcement 

18 activities undertaken by the Secretary under 

19 this subsection. Such information shall be up20 dated in real time and include— 

21 ‘‘(i) the number of reviews of compli22 ance with this subsection undertaken by 

23 the Secretary; 
36 

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1 ‘‘(ii) the number of notifications de2 scribed in subparagraph (A)(i) sent by the 

3 Secretary; 

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

5 was sent such a notification and a descrip6 tion of the nature of such hospital’s non7 compliance with this subsection; 

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

9 penalty imposed on such hospital under 

10 subparagraph (B); 

11 ‘‘(v) whether such hospital subse12 quently came into compliance with this 

13 subsection; 

14 ‘‘(vi) any waivers or reductions of 

15 penalties made pursuant to a certification 

16 by the Secretary under subparagraph 

17 (B)(iv), including— 

18 ‘‘(I) the name of any hospital 

19 that received such a waiver or reduc20 tion; 

21 ‘‘(II) the dollar amount of each 

22 such penalty so waived or reduced; 

23 and 
37 

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1 ‘‘(III) the rationale for the grant2 ing of each such waiver or reduction; 

3 and 

4 ‘‘(vii) any other information as deter5 mined by the Secretary. 

6 ‘‘(5) ENSURING ACCESSIBILITY THROUGH IM7 PLEMENTATION.—In implementing the amendments 

8 made by this section, the Secretary of Health and 

9 Human Services shall through rulemaking ensure 

10 that a hospital submitting charges and information 

11 pursuant to such amendments takes reasonable 

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

13 accessibility of such charges and information to indi14 viduals with limited English proficiency. Such steps 

15 may include the hospital’s provision of interpretation 

16 services or the hospital’s provision of translations of 

17 charges and information. 

18 ‘‘(6) DEFINITIONS.—For purposes of this sub19 section: 

20 ‘‘(A) DISCOUNTED CASH PRICE.—The 

21 term ‘discounted cash price’ means the charge 

22 that applies to an individual who pays cash, or 

23 cash equivalent, for a hospital-furnished item or 

24 service. 
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1 ‘‘(B) FEDERAL HEALTH CARE PROGRAM.— 

2 The term ‘Federal health care program’ has the 

3 meaning given such term in section 1128B of 

4 the Social Security Act. 

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

6 charge’ means the charge for an individual item 

7 or service that is reflected on a hospital’s 

8 chargemaster, absent any discounts. 

9 ‘‘(D) PAYER-SPECIFIC NEGOTIATED

10 CHARGE.—The term ‘payer-specific negotiated 

11 charge’ means the charge that a hospital has 

12 negotiated with a third party payer for an item 

13 or service. 

14 ‘‘(E) SHOPPABLE SERVICE.—The term 

15 ‘shoppable service’ means a service that can be 

16 scheduled by a health care consumer in advance 

17 and includes all ancillary items and services 

18 customarily furnished as part of such service. 

19 ‘‘(F) THIRD PARTY PAYER.—The term 

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

21 statute, contract, or agreement, legally respon22 sible for payment of a claim for a health care 

23 item or service.’’. 
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1 (2) CONFORMING AMENDMENTS.—Section 2718 

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

3 18) is amended— 

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

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

6 after ‘‘this section’’; and 

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

8 the following new sentence: ‘‘The preceding pro9 visions of this subsection shall not apply begin10 ning on January 1, 2026.’’. 

11 (3) EFFECTIVE DATE.—The amendments made 

12 by this subsection shall apply beginning January 1, 

13 2026. 

14 (c) ACCESSIBILITY THROUGH IMPLEMENTATION.— 

15 In implementing the amendments made by this section, 

16 the Secretary of Health and Human Services shall 

17 through rulemaking ensure that a hospital submitting 

18 charges and information pursuant to such amendments 

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

20 ensure the accessibility of such charges and information 

21 to individuals with limited English proficiency. Such steps 

22 may include the hospital’s provision of interpretation serv23 ices or the hospital’s provision of translations of charges 

24 and information. 
40 

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1 SEC. 102. CLINICAL DIAGNOSTIC LABORATORY TEST PRICE 

2 TRANSPARENCY. 

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

4 1395w–2) is amended— 

5 (1) in the header, by inserting ‘‘AND ADDI6 TIONAL REQUIREMENTS’’ after ‘‘SANCTIONS’’; 

7 and 

8 (2) by adding at the end the following new sub9 section: 

10 ‘‘(c) PRICE TRANSPARENCY REQUIREMENT.— 

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

12 2026, any applicable laboratory that receives pay13 ment under this title for furnishing any specified 

14 clinical diagnostic laboratory test under this title 

15 shall— 

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

17 website the information described in paragraph 

18 (2) with respect to each such specified clinical 

19 diagnostic laboratory test that such laboratory 

20 so furnishes; and 

21 ‘‘(B) ensure that such information is up22 dated not less frequently than annually. 

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

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

25 paragraph is, with respect to an applicable labora-
41 

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1 tory and a specified clinical diagnostic laboratory 

2 test, the following: 

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

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

5 charge for such test). 

6 ‘‘(B) The deidentified minimum payer-spe7 cific negotiated charge between such laboratory 

8 and any third party payer for such test. 

9 ‘‘(C) The deidentified maximum payer-spe10 cific negotiated charge between such laboratory 

11 and any third party payer for such test. 

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

13 later than January 1, 2026, the Secretary shall es14 tablish a standard, uniform method and format for 

15 applicable laboratories to use in compiling and mak16 ing public information pursuant to paragraph (1). 

17 Such method and format— 

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

19 available by the Centers for Medicare & Med20 icaid Services (as described in section 

21 1899C(a)(2)(C)(ii)); 

22 ‘‘(B) shall meet such standards as deter23 mined appropriate by the Secretary in order to 

24 ensure the accessibility and usability of such in25 formation; and 
42 

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1 ‘‘(C) shall be updated as determined ap2 propriate by the Secretary, in consultation with 

3 stakeholders. 

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

5 Any price or rate for a specified clinical diagnostic 

6 laboratory test available to be furnished by an appli7 cable laboratory made publicly available in accord8 ance with paragraph (1) shall include the price or 

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

10 (such as specimen collection services) that would 

11 normally be furnished by such laboratory as part of 

12 such test, as specified by the Secretary. 

13 ‘‘(5) ENFORCEMENT.— 

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

15 Secretary determines that an applicable labora16 tory is not in compliance with paragraph (1)— 

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

18 determination, the Secretary shall notify 

19 such laboratory of such determination; and 

20 ‘‘(ii) if such laboratory continues to 

21 fail to comply with such paragraph after 

22 the date that is 90 days after such notifi23 cation is sent, the Secretary may impose a 

24 civil monetary penalty in an amount not to 

25 exceed $300 for each (beginning with the 
43 

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1 day on which the Secretary first deter2 mined that such laboratory was failing to 

3 comply with such paragraph) during which 

4 such failure is ongoing. 

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

6 this paragraph with respect to violations occur7 ring in 2027 or a subsequent year, the Sec8 retary may through notice and comment rule9 making increase the per day limitation on civil 

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

11 ‘‘(C) APPLICATION OF CERTAIN PROVI12 SIONS.—The provisions of section 1128A (other 

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

14 shall apply to a civil monetary penalty imposed 

15 under this paragraph in the same manner as 

16 such provisions apply to a civil monetary pen17 alty imposed under subsection (a) of such sec18 tion. 

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

20 The Secretary shall, to the extent practicable, pro21 vide technical assistance relating to compliance with 

22 the provisions of this subsection to applicable labora23 tories requesting such assistance. 

24 ‘‘(7) DEFINITIONS.—In this subsection: 
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1 ‘‘(A) APPLICABLE LABORATORY.—The 

2 term ‘applicable laboratory’ has the meaning 

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

4 Code of Federal Regulations (or a successor 

5 regulation), except that such term does not in6 clude a laboratory with respect to which stand7 ard charges and prices for specified clinical di8 agnostic laboratory tests furnished by such lab9 oratory are made available by a hospital pursu10 ant to section 1899C or section 2718(f) of the 

11 Public Health Service Act. 

12 ‘‘(B) DISCOUNTED CASH PRICE.—The 

13 term ‘discounted cash price’ means the charge 

14 that applies to an individual who pays cash, or 

15 cash equivalent, for an item or service. 

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

17 charge’ means the charge for an individual item 

18 or service that is reflected on an applicable lab19 oratory’s chargemaster, absent any discounts. 

20 ‘‘(D) PAYER-SPECIFIC NEGOTIATED

21 CHARGE.—The term ‘payer-specific negotiated 

22 charge’ means the charge that an applicable 

23 laboratory has negotiated with a third party 

24 payer for an item or service. 
45 

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1 ‘‘(E) SPECIFIED CLINICAL DIAGNOSTIC

2 LABORATORY TEST.—the term ‘specified clinical 

3 diagnostic laboratory test’ means a clinical di4 agnostic laboratory test that is included on the 

5 list of shoppable services specified by the Cen6 ters for Medicare & Medicaid Services (as de7 scribed in section 1899C(a)(2)(A)(ii)(I)), other 

8 than such a test that is only available to be fur9 nished by a single provider of services or sup10 plier. 

11 ‘‘(F) THIRD PARTY PAYER.—The term 

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

13 statute, contract, or agreement, legally respon14 sible for payment of a claim for a health care 

15 item or service.’’. 

16 SEC. 103. IMAGING PRICE TRANSPARENCY. 

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

18 by section 101, is amended— 

19 (1) by redesignating subsection (b) as sub20 section (c); 

21 (2) by inserting after subsection (a) the fol22 lowing new subsection: 

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

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

25 2028, each provider of services and supplier that re-
46 

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1 ceives payment under this title for furnishing a spec2 ified imaging service, other than such a provider or 

3 supplier with respect to which standard charges and 

4 prices for such services furnished by such provider 

5 or supplier are made available by a hospital pursu6 ant to section 1899C or section 2718(f) of the Pub7 lic Health Service Act, shall— 

8 ‘‘(A) make publicly available (in accord9 ance with paragraph (3)) on an internet website 

10 the information described in paragraph (2) with 

11 respect to each such service that such provider 

12 of services or supplier furnishes; and 

13 ‘‘(B) ensure that such information is up14 dated not less frequently than annually. 

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

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

17 paragraph is, with respect to a provider of services 

18 or supplier and a specified imaging service, the fol19 lowing: 

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

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

22 charge for such service). 

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

24 deidentified minimum payer-specific negotiated 

25 charge for such service and the deidentified 
47 

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1 maximum payer-specific negotiated charge for 

2 such service. 

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

4 later than January 1, 2028, the Secretary shall es5 tablish a standard, uniform method and format for 

6 providers of services and suppliers to use in making 

7 public information described in paragraph (2). Any 

8 such method and format— 

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

10 available by the Centers for Medicare & Med11 icaid Services (as described in section 

12 1899C(a)(2)(C)(ii)); 

13 ‘‘(B) shall meet such standards as deter14 mined appropriate by the Secretary in order to 

15 ensure the accessibility and usability of such in16 formation; and 

17 ‘‘(C) shall be updated as determined ap18 propriate by the Secretary, in consultation with 

19 stakeholders. 

20 ‘‘(4) MONITORING COMPLIANCE.—The Sec21 retary shall, through notice and comment rule22 making and in consultation with the Inspector Gen23 eral of the Department of Health and Human Serv24 ices, establish a process to monitor compliance with 

25 this subsection. 
48 

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1 ‘‘(5) ENFORCEMENT.— 

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

3 Secretary determines that a provider of services 

4 or supplier is not in compliance with paragraph 

5 (1)— 

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

7 determination, the Secretary shall notify 

8 such provider or supplier of such deter9 mination; 

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

11 such provider or supplier shall submit to 

12 the Secretary, not later than 45 days after 

13 the date of such request, a corrective ac14 tion plan to comply with such paragraph; 

15 and 

16 ‘‘(iii) if such provider or supplier con17 tinues to fail to comply with such para18 graph after the date that is 90 days after 

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

20 such a provider or supplier that has sub21 mitted a corrective action plan described in 

22 clause (ii) in response to a request so de23 scribed, after the date that is 90 days after 

24 such submission), the Secretary may im25 pose a civil monetary penalty in an amount 
49 

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1 not to exceed $300 for each day (beginning 

2 with the day on which the Secretary first 

3 determined that such provider or supplier 

4 was failing to comply with such paragraph) 

5 during which such failure to comply or fail6 ure to submit is ongoing. 

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

8 this paragraph with respect to violations occur9 ring in 2029 or a subsequent year, the Sec10 retary may through notice and comment rule11 making increase the amount of the civil mone12 tary penalty under subparagraph (A)(iii). 

13 ‘‘(C) APPLICATION OF CERTAIN PROVI14 SIONS.—The provisions of section 1128A (other 

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

16 shall apply to a civil monetary penalty imposed 

17 under this paragraph in the same manner as 

18 such provisions apply to a civil monetary pen19 alty imposed under subsection (a) of such sec20 tion. 

21 ‘‘(D) AUTHORITY TO WAIVE OR REDUCE

22 PENALTY.— 

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

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

25 penalty otherwise applicable with respect to 
50 

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1 a provider of services or supplier under 

2 this subparagraph if the Secretary certifies 

3 that imposition of such penalty would re4 sult in an immediate threat to access to 

5 care for individuals in the service area of 

6 such provider or supplier. 

7 ‘‘(ii) LIMITATION.—The Secretary 

8 may not elect to waive or reduce a penalty 

9 under clause (i) with respect to a specific 

10 provider of services or supplier more than 

11 3 times. 

12 ‘‘(E) PROVISION OF TECHNICAL ASSIST13 ANCE.—The Secretary shall, to the extent prac14 ticable, provide technical assistance relating to 

15 compliance with the provisions of this sub16 section to providers of services and suppliers re17 questing such assistance. 

18 ‘‘(F) CLARIFICATION OF NONAPPLICA19 BILITY OF OTHER ENFORCEMENT PROVI20 SIONS.—Notwithstanding any other provision of 

21 this title, this paragraph shall be the sole 

22 means of enforcing the provisions of this sub23 section.’’; and 

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

25 paragraph (1)— 
51 

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1 (A) by redesignating paragraph (8) as 

2 paragraph (9); and 

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

4 following new paragraph: 

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

6 ‘specified imaging service’ means an imaging service 

7 that is a Centers for Medicare & Medicaid Services8 specified shoppable service (as described in sub9 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 ambulatory surgical center that receives 

10 payment under this title for furnishing items and 

11 services shall comply with the price transparency re12 quirement 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 an ambulatory surgical center, that such sur18 gical center in accordance with a method and 

19 format established by the Secretary under sub20 paragraph (C), compile and make public (with21 out subscription and free of charge), for each 

22 year— 

23 ‘‘(i) all of the ambulatory surgical 

24 center’s standard charges (including the 

25 information described in subparagraph 
53 

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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) 
54 

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1 made public by an ambulatory surgical center, 

2 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. 
55 

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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 ambulatory surgical centers to use in 

16 making public standard charges and a stand17 ard, uniform method and format for such cen18 ters to use in making public prices pursuant to 

19 subparagraph (A). Any such method and for20 mat— 

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 ambulatory surgical center’s compliance with this 

19 subsection is reviewed not less frequently than once 

20 every 3 years. 

21 ‘‘(4) ENFORCEMENT.— 

22 ‘‘(A) IN GENERAL.—In the case of an am23 bulatory surgical center that fails to comply 

24 with the requirements of this subsection— 
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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 an ambulatory surgical center that has re17 ceived a notification under subparagraph 

18 (A)(i) and fails to comply with the require19 ments of this subsection by the date that 

20 is 90 days after such notification (or, in 

21 the case of an ambulatory surgical center 

22 that has submitted a corrective action plan 

23 described in subparagraph (A)(ii) in re24 sponse 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 an ambulatory sur13 gical 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 
59 

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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 an ambulatory 

5 surgical center located in a rural or 

6 underserved area if the Secretary cer7 tifies that imposition of such penalty 

8 would result in an immediate threat 

9 to access to care for individuals in the 

10 service area of such surgical center. 

11 ‘‘(II) LIMITATION ON APPLICA12 TION.—The Secretary may not elect 

13 to waive a penalty under subclause (I) 

14 with respect to an ambulatory surgical 

15 center more than once in a 6-year pe16 riod and may not elect to reduce such 

17 a penalty with respect to such a sur18 gical center more than once in such a 

19 period. Nothing in the preceding sen20 tence shall be construed as prohibiting 

21 the Secretary from both waiving and 

22 reducing a penalty with respect to an 

23 ambulatory surgical center during a 

24 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 an ambulatory 

14 surgical 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 an ambulatory 
61 

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1 surgical center has negotiated with a third 

2 party 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) THIRD PARTY PAYER.—The term 

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

10 statute, contract, or agreement, legally respon11 sible for payment of a claim for a health care 

12 item or service.’’. 

13 SEC. 105. HEALTH COVERAGE PRICE TRANSPARENCY. 

14 (a) PRICE TRANSPARENCY REQUIREMENTS.— 

15 (1) IRC.— 

16 (A) IN GENERAL.—Section 9819 of the In17 ternal Revenue Code of 1986 is amended to 

18 read as follows: 

19 ‘‘SEC. 9819. TRANSPARENCY IN COVERAGE. 

20 ‘‘(a) COST-SHARING TRANSPARENCY.— 

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

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

23 shall permit a participant or beneficiary to learn the 

24 amount of cost-sharing (including deductibles, co25 payments, and coinsurance) under the participant or 
62 

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1 beneficiary’s plan that the participant or beneficiary 

2 would be responsible for paying with respect to the 

3 furnishing of a specific item or service by a provider 

4 in a timely manner upon the request of the partici5 pant or beneficiary. At a minimum, such information 

6 shall include the information specified in paragraph 

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

8 or beneficiary through a self-service tool that meets 

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

10 of such participant or beneficiary, through a paper 

11 disclosure or phone or other electronic disclosure (as 

12 selected by such participant or beneficiary and pro13 vided at no cost to such participant or beneficiary) 

14 that meets such requirements as the Secretary may 

15 specify. 

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

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

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

19 which benefits are available under a group health 

20 plan furnished by a health care provider to a partici21 pant or beneficiary of such plan, the following: 

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

23 provider with respect to such item or service, 

24 the in-network rate (as defined in subsection 

25 (c)) for such item or service. 
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1 ‘‘(B) If such provider is not a participating 

2 provider with respect to such item or service, 

3 the maximum allowed amount or other dollar 

4 amount that such plan or coverage will recog5 nize as payment for such item or service, along 

6 with a notice that such participant or bene7 ficiary may be liable for additional charges. 

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

9 (including deductibles, copayments, and coin10 surance) that the participant or beneficiary will 

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

12 case such item or service is to be furnished by 

13 a provider described in subparagraph (B), shall 

14 be calculated using the maximum allowed 

15 amount or other dollar amount described in 

16 such subparagraph). 

17 ‘‘(D) The amount the participant or bene18 ficiary has already accumulated with respect to 

19 any deductible or out of pocket maximum under 

20 the plan (broken down, in the case separate 

21 deductibles or maximums apply to separate par22 ticipants and beneficiaries enrolled in the plan, 

23 by such separate deductibles or maximums, in 

24 addition to any cumulative deductible or max25 imum). 
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1 ‘‘(E) In the case such plan imposes any 

2 frequency or volume limitations with respect to 

3 such item or service (excluding medical neces4 sity determinations), the amount that such par5 ticipant or beneficiary has accrued towards such 

6 limitation with respect to such item or service. 

7 ‘‘(F) Any prior authorization, concurrent 

8 review, step therapy, fail first, or similar re9 quirements applicable to coverage of such item 

10 or service under such plan. 

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

12 credit, payment, or other benefit provided by 

13 such plan) available to the participant or bene14 ficiary with respect to such item or service fur15 nished by such provider known at the time such 

16 request is made. 

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

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

19 group health plan meets the requirements of this 

20 paragraph if such tool— 

21 ‘‘(A) is based on an Internet website (or 

22 successor technology specified by the Sec23 retary); 

24 ‘‘(B) provides for real-time responses to re25 quests described in paragraph (1); 
65 

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

3 and accurate at the time such request is made; 

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

5 with respect to an item or service furnished 

6 by— 

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

9 item or service; or 

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

12 or service; 

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 Sec-
66 

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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 (other than a grandfathered health plan (as defined 

7 in section 1251(e) of the Patient Protection and Af8 fordable Care Act)) shall, for each month, not later 

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

10 the public the rate and payment information de11 scribed in paragraph (2) in accordance with para12 graph (3). 

13 ‘‘(2) RATE AND PAYMENT INFORMATION DE14 SCRIBED.—For purposes of paragraph (1), the rate 

15 and payment information described in this para16 graph is, with respect to a group health plan, the 

17 following: 

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

19 (other than a drug) for which benefits are avail20 able under such plan, the in-network rate (ex21 pressed as a dollar amount) in effect as of the 

22 date on which such information is made public 

23 with each provider that is a participating pro24 vider with respect to such item or service. 
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1 ‘‘(B) With respect to each drug (identified 

2 by national drug code) for which benefits are 

3 available under such plan— 

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

5 a dollar amount) in effect as of the first 

6 day of the month in which such informa7 tion is made public with each provider that 

8 is a participating provider with respect to 

9 such drug; and 

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

11 plan (net of rebates, discounts, and price 

12 concessions) for such drug dispensed or 

13 administered during the 90-day period be14 ginning 180 days before such date of pub15 lication to each provider that was a partici16 pating provider with respect to such drug, 

17 broken down by each such provider, other 

18 than such an amount paid to a provider 

19 that, during such period, submitted fewer 

20 than 20 claims for such drug to such plan. 

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

22 for which benefits are available under such 

23 plan, the amount billed, and the amount al24 lowed by the plan, for each such item or service 

25 furnished during the 90-day period specified in 
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1 subparagraph (B) by a provider that was not a 

2 participating provider with respect to such item 

3 or service, broken down by each such provider. 

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

5 payment information required to be made available 

6 under this subsection shall be so made available in 

7 dollar amounts through separate machine-readable 

8 files (and any successor technology, such as applica9 tion program interface technology, determined ap10 propriate by the Secretary) corresponding to the in11 formation described in each of subparagraphs (A) 

12 through (C) of paragraph (2) that meet such re13 quirements as specified by the Secretary through 

14 subregulatory guidance. Such requirements shall en15 sure that such files are limited to an appropriate 

16 size, do not include disclosure of unnecessary dupli17 cative information contained in other files made 

18 available under this subsection, are made available 

19 in a widely available format through a publicly avail20 able website that allows for information contained in 

21 such files to be compared across group health plans 

22 and group or individual health insurance coverage, 

23 and are accessible to individuals at no cost and with24 out the need to establish a user account or provide 

25 other credentials. 
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1 ‘‘(4) USER INSTRUCTIONS.—Each group health 

2 plan shall make available to the public instructions 

3 written in plain language explaining how individuals 

4 may search for information described in paragraph 

5 (2) in files submitted in accordance with paragraph 

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

7 subregulatory guidance a template that such a plan 

8 may use in developing instructions for purposes of 

9 the preceding sentence. 

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

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

12 shall make public a data file, in a manner that en13 sures that such file may be easily downloaded and 

14 read by standard spreadsheet software and that 

15 meets such requirements as established by the Sec16 retary, containing a summary of all rate and pay17 ment information made public by such plan with re18 spect to such plan during such plan year. Such file 

19 shall include the following: 

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

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

22 allowed for an item or service when not fur23 nished by a participating provider, in effect as 

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

25 or service (identified by payer identifier ap-
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1 proved or used by the Centers for Medicare & 

2 Medicaid Services) for which benefits are avail3 able under the plan, broken down by the type 

4 of provider furnishing the item or service and 

5 by the geographic area in which such item or 

6 service is furnished. 

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

8 items and services over such plan year, includ9 ing an identification of instances in which such 

10 rates have increased, decreased, or remained 

11 the same. 

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

13 of the type of network of participating providers 

14 used by such plan, and a description of whether 

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

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

17 paid as part of a bundled rate— 

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

19 pricing methodologies, or other information 

20 used to calculate the payment rate for such 

21 bundle; and 

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

23 included in such bundle. 

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

25 that are paid for on a fee-for-service basis and 
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1 the percentage of items and services that are 

2 paid for as part of a bundled rate, capitated 

3 payment rate, or other alternative payment 

4 model. 

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

6 shall post, along with rate and payment information 

7 made public by such plan, an attestation that such 

8 information is complete and accurate. 

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

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

11 that information provided in response to a request de12 scribed in subsection (a), and rate and payment informa13 tion made public under subsection (b), is provided in plain, 

14 easily understandable language and that interpretation, 

15 translations, and assistive services are provided to those 

16 with limited English proficiency and those with disabil17 ities. 

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

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

20 ‘participating provider’ means, with respect to an 

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

22 or other health care provider who is acting within 

23 the scope of practice of that provider’s license or cer24 tification under applicable State law and who has a 

25 contractual relationship with the plan, respectively, 
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1 for furnishing such item or service under the plan, 

2 and includes facilities, respectively. 

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

4 a health care facility. 

5 ‘‘(3) IN-NETWORK RATE.—The term ‘in-net6 work rate’ means, with respect to a group health 

7 plan and an item or service furnished by a provider 

8 that is a participating provider with respect to such 

9 plan and item or service, the contracted rate (re10 flected as a dollar amount) in effect between such 

11 plan and such provider for such item or service, re12 gardless of whether such rate is calculated based on 

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

14 from another amount, or a formula, or other meth15 od.’’. 

16 (B) CLERICAL AMENDMENT.—The item re17 lating to section 9819 of the table of sections 

18 for subchapter B of chapter 100 of the Internal 

19 Revenue Code of 1986 is amended to read as 

20 follows: 

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

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

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

23 amended to read as follows: 

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

25 ‘‘(a) COST-SHARING TRANSPARENCY.— 
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1 ‘‘(1) IN GENERAL.—For plan years beginning 

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

3 and a health insurance issuer offering group or indi4 vidual health insurance coverage shall permit an in5 dividual enrolled under such plan or coverage to 

6 learn the amount of cost-sharing (including 

7 deductibles, copayments, and coinsurance) under the 

8 individual’s plan or coverage that the individual 

9 would be responsible for paying with respect to the 

10 furnishing of a specific item or service by a provider 

11 in a timely manner upon the request of the indi12 vidual. At a minimum, such information shall in13 clude the information specified in paragraph (2) and 

14 shall be made available to such individual through a 

15 self-service tool that meets the requirements of para16 graph (3) or, at the option of such individual, 

17 through a paper disclosure or phone or other elec18 tronic disclosure (as selected by such individual and 

19 provided at no cost to such individual) that meets 

20 such requirements as the Secretary may specify. 

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

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

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

24 which benefits are available under a group health 

25 plan or group or individual health insurance cov-
74 

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1 erage furnished by a health care provider to an indi2 vidual enrolled under such plan or coverage, the fol3 lowing: 

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

5 provider with respect to such item or service, 

6 the in-network rate (as defined in subsection 

7 (c)) for such item or service. 

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

9 provider with respect to such item or service, 

10 the maximum allowed amount or other dollar 

11 amount that such plan or coverage will recog12 nize as payment for such item or service, along 

13 with a notice that such individual may be liable 

14 for additional charges. 

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

16 (including deductibles, copayments, and coin17 surance) that the individual will incur for such 

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

19 service is to be furnished by a provider de20 scribed in subparagraph (B), shall be calculated 

21 using the maximum allowed amount or other 

22 dollar amount described in such subparagraph). 

23 ‘‘(D) The amount the individual has al24 ready accumulated with respect to any deduct25 ible or out of pocket maximum under the plan 
75 

•HR 5378 EH

1 or coverage (broken down, in the case separate 

2 deductibles or maximums apply to separate in3 dividuals enrolled in the plan or coverage, by 

4 such separate deductibles or maximums, in ad5 dition to any cumulative deductible or max6 imum). 

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

8 frequency or volume limitations with respect to 

9 such item or service (excluding medical neces10 sity determinations), the amount that such indi11 vidual has accrued towards such limitation with 

12 respect to such item or service. 

13 ‘‘(F) Any prior authorization, concurrent 

14 review, step therapy, fail first, or similar re15 quirements applicable to coverage of such item 

16 or service under such plan or coverage. 

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

18 credit, payment, or other benefit provided by 

19 such plan or issuer) available to the individual 

20 with respect to such item or service furnished 

21 by such provider known at the time such re22 quest is made. 

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

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

25 group health plan or health insurance issuer offering 
76 

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1 group or individual health insurance coverage meets 

2 the requirements of this paragraph if such tool— 

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

4 successor technology specified by the Sec5 retary); 

6 ‘‘(B) provides for real-time responses to re7 quests described in paragraph (1); 

8 ‘‘(C) is updated in a manner such that in9 formation provided through such tool is timely 

10 and accurate at the time such request is made; 

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

12 with respect to an item or service furnished 

13 by— 

14 ‘‘(i) a specific provider that is a par15 ticipating provider with respect to such 

16 item or service; or 

17 ‘‘(ii) all providers that are partici18 pating providers with respect to such item 

19 or service; 

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

21 made with respect to an item or service through 

22 use of the billing code for such item or service 

23 or through use of a descriptive term for such 

24 item or service; and 
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1 ‘‘(F) meets any other requirement deter2 mined appropriate by the Secretary to ensure 

3 the accessibility and usability of information 

4 provided through such tool. 

5 The Secretary may require such tool, as a condition 

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

7 billing codes to a single descriptive term if the Sec8 retary determines that the billing codes to be so 

9 linked correspond to similar items and services. 

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

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

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

13 and health insurance issuer offering group or indi14 vidual health insurance coverage (other than a 

15 grandfathered health plan (as defined in section 

16 1251(e) of the Patient Protection and Affordable 

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

18 tenth day of such month, make available to the pub19 lic the rate and payment information described in 

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

21 ‘‘(2) RATE AND PAYMENT INFORMATION DE22 SCRIBED.—For purposes of paragraph (1), the rate 

23 and payment information described in this para24 graph is, with respect to a group health plan or 
78 

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1 group or individual health insurance coverage, the 

2 following: 

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

4 (other than a drug) for which benefits are avail5 able under such plan or coverage, the in-net6 work rate (expressed as a dollar amount) in ef7 fect as of the date on which such information 

8 is made public with each provider that is a par9 ticipating provider with respect to such item or 

10 service. 

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

12 by national drug code) for which benefits are 

13 available under such plan or coverage— 

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

15 a dollar amount) in effect as of the first 

16 day of the month in which such informa17 tion is made public with each provider that 

18 is a participating provider with respect to 

19 such drug; and 

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

21 plan (net of rebates, discounts, and price 

22 concessions) for such drug dispensed or 

23 administered during the 90-day period be24 ginning 180 days before such date of pub25 lication to each provider that was a partici-
79 

•HR 5378 EH

1 pating provider with respect to such drug, 

2 broken down by each such provider, other 

3 than such an amount paid to a provider 

4 that, during such period, submitted fewer 

5 than 20 claims for such drug to such plan 

6 or coverage. 

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

8 for which benefits are available under such plan 

9 or coverage, the amount billed, and the amount 

10 allowed by the plan, for each such item or serv11 ice furnished during the 90-day period specified 

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

13 a participating provider with respect to such 

14 item or service, broken down by each such pro15 vider. 

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

17 payment information required to be made available 

18 under this subsection shall be so made available in 

19 dollar amounts through separate machine-readable 

20 files (and any successor technology, such as applica21 tion program interface technology, determined ap22 propriate by the Secretary) corresponding to the in23 formation described in each of subparagraphs (A) 

24 through (C) of paragraph (2) that meet such re25 quirements as specified by the Secretary through 
80 

•HR 5378 EH

1 subregulatory guidance. Such requirements shall en2 sure that such files are limited to an appropriate 

3 size, do not include disclosure of unnecessary dupli4 cative information contained in other files made 

5 available under this subsection, are made available 

6 in a widely-available format through a publicly-avail7 able website that allows for information contained in 

8 such files to be compared across group health plans 

9 and group or individual health insurance coverage, 

10 and are accessible to individuals at no cost and with11 out the need to establish a user account or provide 

12 other credentials. 

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

14 plan and health insurance issuer offering group or 

15 individual health insurance coverage shall make 

16 available to the public instructions written in plain 

17 language explaining how individuals may search for 

18 information described in paragraph (2) in files sub19 mitted in accordance with paragraph (3). The Sec20 retary shall develop and publish through subregu21 latory guidance a template that such a plan may use 

22 in developing instructions for purposes of the pre23 ceding sentence. 

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

25 on or after January 1, 2026, each group health plan 
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•HR 5378 EH

1 and health insurance issuer offering group or indi2 vidual health insurance coverage shall make public a 

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

4 may be easily downloaded and read by standard 

5 spreadsheet software and that meets such require6 ments as established by the Secretary, containing a 

7 summary of all rate and payment information made 

8 public by such plan or issuer with respect to such 

9 plan or coverage during such plan year. Such file 

10 shall include the following: 

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

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

13 allowed for an item or service when not fur14 nished by a participating provider, in effect as 

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

16 or service (identified by payer identifier ap17 proved or used by the Centers for Medicare & 

18 Medicaid Services) for which benefits are avail19 able under the plan or coverage, broken down 

20 by the type of provider furnishing the item or 

21 service and by the geographic area in which 

22 such item or service is furnished. 

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

24 items and services over such plan year, includ25 ing an identification of instances in which such 
82 

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1 rates have increased, decreased, or remained 

2 the same. 

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

4 of the type of network of participating providers 

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

6 of a group health plan, a description of whether 

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

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

9 paid as part of a bundled rate— 

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

11 pricing methodologies, or other information 

12 used to calculate the payment rate for such 

13 bundle; and 

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

15 included in such bundle. 

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

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

18 the percentage of items and services that are 

19 paid for as part of a bundled rate, capitated 

20 payment rate, or other alternative payment 

21 model. 

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

23 and health insurance issuer offering group or indi24 vidual health insurance coverage shall post, along 

25 with rate and payment information made public by 
83 

•HR 5378 EH

1 such plan or issuer, an attestation that such infor2 mation is complete and accurate. 

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

4 health insurance issuer offering group or individual health 

5 insurance coverage shall take reasonable steps (as speci6 fied by the Secretary) to ensure that information provided 

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

8 rate and payment information made public under sub9 section (b), is provided in plain, easily understandable lan10 guage and that interpretation, translations, and assistive 

11 services are provided to those with limited English pro12 ficiency and those with disabilities. 

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

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

15 ‘participating provider’ means, with respect to an 

16 item or service and a group health plan or health in17 surance issuer offering group or individual health in18 surance coverage, a physician or other health care 

19 provider who is acting within the scope of practice 

20 of that provider’s license or certification under appli21 cable State law and who has a contractual relation22 ship with the plan or issuer, respectively, for fur23 nishing such item or service under the plan or cov24 erage, and includes facilities, respectively. 
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1 ‘‘(2) PROVIDER.—The term ‘provider’ includes 

2 a health care facility. 

3 ‘‘(3) IN-NETWORK RATE.—The term ‘in-net4 work rate’ means, with respect to a group health 

5 plan or group or individual health insurance cov6 erage and an item or service furnished by a provider 

7 that is a participating provider with respect to such 

8 plan or coverage and item or service, the contracted 

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

10 such plan or coverage and such provider for such 

11 item or service, regardless of whether such rate is 

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

13 an amount derived from another amount, or a for14 mula, or other method.’’. 

15 (3) ERISA.— 

16 (A) IN GENERAL.—Section 719 of the Em17 ployee Retirement Income Security Act of 1974 

18 (29 U.S.C. 1185h) is amended to read as fol19 lows: 

20 ‘‘SEC. 719. TRANSPARENCY IN COVERAGE. 

21 ‘‘(a) COST-SHARING TRANSPARENCY.— 

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

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

24 and a health insurance issuer offering group health 

25 insurance coverage shall permit a participant or ben-
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1 eficiary to learn the amount of cost-sharing (includ2 ing deductibles, copayments, and coinsurance) under 

3 the participant or beneficiary’s plan or coverage that 

4 the participant or beneficiary would be responsible 

5 for paying with respect to the furnishing of a spe6 cific item or service by a provider in a timely man7 ner upon the request of the participant or bene8 ficiary. At a minimum, such information shall in9 clude the information specified in paragraph (2) and 

10 shall be made available to such participant or bene11 ficiary through a self-service tool that meets the re12 quirements of paragraph (3) or, at the option of 

13 such participant or beneficiary, through a paper dis14 closure or phone or other electronic disclosure (as 

15 selected by such participant or beneficiary and pro16 vided at no cost to such participant or beneficiary) 

17 that meets such requirements as the Secretary may 

18 specify. 

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

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

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

22 which benefits are available under a group health 

23 plan or group health insurance coverage furnished 

24 by a health care provider to a participant or bene25 ficiary of such plan or coverage, the following: 
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1 ‘‘(A) If such provider is a participating 

2 provider with respect to such item or service, 

3 the in-network rate (as defined in subsection 

4 (c)) for such item or service. 

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

6 provider with respect to such item or service, 

7 the maximum allowed amount or other dollar 

8 amount that such plan or coverage will recog9 nize as payment for such item or service, along 

10 with a notice that such participant or bene11 ficiary may be liable for additional charges. 

12 ‘‘(C) The estimated amount of cost-sharing 

13 (including deductibles, copayments, and coin14 surance) that the participant or beneficiary will 

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

16 case such item or service is to be furnished by 

17 a provider described in subparagraph (B), shall 

18 be calculated using the maximum allowed 

19 amount or other dollar amount described in 

20 such subparagraph). 

21 ‘‘(D) The amount the participant or bene22 ficiary has already accumulated with respect to 

23 any deductible or out of pocket maximum under 

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

25 separate deductibles or maximums apply to sep-
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1 arate participants and beneficiaries enrolled in 

2 the plan or coverage, by such separate 

3 deductibles or maximums, in addition to any 

4 cumulative deductible or maximum). 

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

6 frequency or volume limitations with respect to 

7 such item or service (excluding medical neces8 sity determinations), the amount that such par9 ticipant or beneficiary has accrued towards such 

10 limitation with respect to such item or service. 

11 ‘‘(F) Any prior authorization, concurrent 

12 review, step therapy, fail first, or similar re13 quirements applicable to coverage of such item 

14 or service under such plan or coverage. 

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

16 credit, payment, or other benefit provided by 

17 such plan or issuer) available to the participant 

18 or beneficiary with respect to such item or serv19 ice furnished by such provider known at the 

20 time such request is made. 

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

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

23 group health plan or health insurance issuer offering 

24 group health insurance coverage meets the require25 ments of this paragraph if such tool— 
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1 ‘‘(A) is based on an internet website (or 

2 successor technology specified by the Sec3 retary); 

4 ‘‘(B) provides for real-time responses to re5 quests described in paragraph (1); 

6 ‘‘(C) is updated in a manner such that in7 formation provided through such tool is timely 

8 and accurate at the time such request is made; 

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

10 with respect to an item or service furnished 

11 by— 

12 ‘‘(i) a specific provider that is a par13 ticipating provider with respect to such 

14 item or service; or 

15 ‘‘(ii) all providers that are partici16 pating providers with respect to such item 

17 or service; 

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

19 made with respect to an item or service through 

20 use of the billing code for such item or service 

21 or through use of a descriptive term for such 

22 item or service; and 

23 ‘‘(F) meets any other requirement deter24 mined appropriate by the Secretary to ensure 
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1 the accessibility and usability of information 

2 provided through such tool. 

3 The Secretary may require such tool, as a condition 

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

5 billing codes to a single descriptive term if the Sec6 retary determines that the billing codes to be so 

7 linked correspond to similar items and services. 

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

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

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

11 and health insurance issuer offering group health in12 surance coverage (other than a grandfathered health 

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

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

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

16 make available to the public the rate and payment 

17 information described in paragraph (2) in accord18 ance with paragraph (3). 

19 ‘‘(2) RATE AND PAYMENT INFORMATION DE20 SCRIBED.—For purposes of paragraph (1), the rate 

21 and payment information described in this para22 graph is, with respect to a group health plan or 

23 group health insurance coverage, the following: 

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

25 (other than a drug) for which benefits are avail-
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1 able under such plan or coverage, the in-net2 work rate (expressed as a dollar amount) in ef3 fect as of the date on which such information 

4 is made public with each provider that is a par5 ticipating provider with respect to such item or 

6 service. 

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

8 by national drug code) for which benefits are 

9 available under such plan or coverage— 

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

11 a dollar amount) in effect as of the first 

12 day of the month in which such informa13 tion is made public with each provider that 

14 is a participating provider with respect to 

15 such drug; and 

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

17 plan (net of rebates, discounts, and price 

18 concessions) for such drug dispensed or 

19 administered during the 90-day period be20 ginning 180 days before such date of pub21 lication to each provider that was a partici22 pating provider with respect to such drug, 

23 broken down by each such provider, other 

24 than such an amount paid to a provider 

25 that, during such period, submitted fewer 
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1 than 20 claims for such drug to such plan 

2 or coverage. 

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

4 for which benefits are available under such plan 

5 or coverage, the amount billed, and the amount 

6 allowed by the plan, for each such item or serv7 ice furnished during the 90-day period specified 

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

9 a participating provider with respect to such 

10 item or service, broken down by each such pro11 vider. 

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

13 payment information required to be made available 

14 under this subsection shall be so made available in 

15 dollar amounts through separate machine-readable 

16 files (and any successor technology, such as applica17 tion program interface technology, determined ap18 propriate by the Secretary) corresponding to the in19 formation described in each of subparagraphs (A) 

20 through (C) of paragraph (2) that meet such re21 quirements as specified by the Secretary through 

22 subregulatory guidance. Such requirements shall en23 sure that such files are limited to an appropriate 

24 size, do not include disclosure of unnecessary dupli25 cative information contained in other files made 
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1 available under this subsection, are made available 

2 in a widely available format through a publicly avail3 able website that allows for information contained in 

4 such files to be compared across group health plans 

5 and group or individual health insurance coverage, 

6 and are accessible to individuals at no cost and with7 out the need to establish a user account or provide 

8 other credentials. 

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

10 plan and health insurance issuer offering group 

11 health insurance coverage shall make available to the 

12 public instructions written in plain language explain13 ing how individuals may search for information de14 scribed in paragraph (2) in files submitted in ac15 cordance with paragraph (3). The Secretary shall 

16 develop and publish through subregulatory guidance 

17 a template that such a plan may use in developing 

18 instructions for purposes of the preceding sentence. 

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

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

21 and health insurance issuer offering group health in22 surance coverage shall make public a data file, in a 

23 manner that ensures that such file may be easily 

24 downloaded and read by standard spreadsheet soft25 ware and that meets such requirements as estab-
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1 lished by the Secretary, containing a summary of all 

2 rate and payment information made public by such 

3 plan or issuer with respect to such plan or coverage 

4 during such plan year. Such file shall include the fol5 lowing: 

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

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

8 allowed for an item or service when not fur9 nished by a participating provider, in effect as 

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

11 or service (identified by payer identifier ap12 proved or used by the Centers for Medicare & 

13 Medicaid Services) for which benefits are avail14 able under the plan or coverage, broken down 

15 by the type of provider furnishing the item or 

16 service and by the geographic area in which 

17 such item or service is furnished. 

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

19 items and services over such plan year, includ20 ing an identification of instances in which such 

21 rates have increased, decreased, or remained 

22 the same. 

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

24 of the type of network of participating providers 

25 used by such plan or coverage, and, in the case 
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1 of a group health plan, a description of whether 

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

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

4 paid as part of a bundled rate— 

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

6 pricing methodologies, or other information 

7 used to calculate the payment rate for such 

8 bundle; and 

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

10 included in such bundle. 

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

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

13 the percentage of items and services that are 

14 paid for as part of a bundled rate, capitated 

15 payment rate, or other alternative payment 

16 model. 

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

18 and health insurance issuer offering group health in19 surance coverage shall post, along with rate and 

20 payment information made public by such plan or 

21 issuer, an attestation that such information is com22 plete and accurate. 

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

24 health insurance issuer offering group health insurance 

25 coverage shall take reasonable steps (as specified by the 
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1 Secretary) to ensure that information provided in response 

2 to a request described in subsection (a), and rate and pay3 ment information made public under subsection (b), is 

4 provided in plain, easily understandable language and that 

5 interpretation, translations, and assistive services are pro6 vided to those with limited English proficiency and those 

7 with disabilities. 

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

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

10 ‘participating provider’ means, with respect to an 

11 item or service and a group health plan or health in12 surance issuer offering group or individual health in13 surance coverage, a physician or other health care 

14 provider who is acting within the scope of practice 

15 of that provider’s license or certification under appli16 cable State law and who has a contractual relation17 ship with the plan or issuer, respectively, for fur18 nishing such item or service under the plan or cov19 erage, and includes facilities, respectively. 

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

21 a health care facility. 

22 ‘‘(3) IN-NETWORK RATE.—The term ‘in-net23 work rate’ means, with respect to a group health 

24 plan or group health insurance coverage and an item 

25 or service furnished by a provider that is a partici-
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1 pating provider with respect to such plan or cov2 erage and item or service, the contracted rate (re3 flected as a dollar amount) in effect between such 

4 plan or coverage and such provider for such item or 

5 service, regardless of whether such rate is calculated 

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

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

8 method.’’. 

9 (B) CLERICAL AMENDMENT.—The table of 

10 contents in section 1 of the Employee Retire11 ment Income Security Act of 1974 is amended 

12 by striking the item relating to section 719 and 

13 inserting the following new item: 

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

14 (b) APPLICATION PROGRAMMING INTERFACE RE15 PORT.—Not later than January 1, 2025, and annually 

16 thereafter, the Secretary of Health and Human Services 

17 shall, in consultation with the Office of the National Coor18 dinator for Health Information Technology, Department 

19 of Labor, the Department of the Treasury, and stake20 holders, submit to the House Committees on Education 

21 and the Workforce, Energy and Commerce, and Ways and 

22 Means, and the Senate Committees on Finance and 

23 Health, Education, Labor, and Pensions a report on the 

24 use of standards-based application programming inter25 faces (in this subsection referred to as ‘‘APIs’’) to facili-
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1 tate access to health care price transparency information 

2 and the interoperability of other medical information. 

3 Such report shall include an evaluation of the capacity of 

4 the Department of Health and Human Services, the De5 partment of Labor, and the Department of the Treasury 

6 to regulate and implement standards related to APIs and 

7 recommendations for improving such capacity. Such re8 port shall include the following: 

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

10 use, of APIs under Federal rules to facilitate inter11 operability, including information related to capacity 

12 constraints within the agencies, barriers to adoption, 

13 privacy and security, administrative burdens and ef14 ficiencies, care coordination, and levels of compli15 ance. 

16 (2) A description of the feasibility of agency 

17 participation in the development of APIs to enable 

18 application access to price transparency data under 

19 the amendments made by subsection (a). 

20 (3) A specification of the timeline for which 

21 such data standards can be required to make such 

22 data accessible via an API. 

23 (4) An analysis of the benefits and challenges 

24 of implementing standards-based APIs for price 

25 transparency data, including the ability for con-
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1 sumers to access rate and payment information and 

2 the amount of cost-sharing (including deductibles, 

3 copayments, and coinsurance) under the consumer’s 

4 plan through third-party internet-based tools and 

5 applications. 

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

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

8 information may have in increasing the amount of 

9 services shoppable for individuals, such as by stand10 ardizing more health care spend via episode bundles. 

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

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

13 which prices change with the greatest frequency. 

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

15 implementation on issuers, employers, and other pri16 vate-sector entities. 

17 (8) An analysis of the ability of State regu18 lators to enforce API standards and the costs to the 

19 Federal Government and States to regulate and en20 force API standards. 

21 (9) An analysis of the interaction with API 

22 standards and Federal health information privacy 

23 standards. 

24 (c) PROVIDER TOOL REPORT.— 
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1 (1) IN GENERAL.—Not later than 1 year after 

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

3 of Health and Human Services, acting through the 

4 Administrator of the Centers for Medicare & Med5 icaid Services, shall, in consultation with stake6 holders, conduct a study and submit to the House 

7 Committees on Education and the Workforce, En8 ergy and Commerce, and Ways and Means, and the 

9 Senate Committees on Finance and Health, Edu10 cation, Labor, and Pensions a report on the useful11 ness and feasibility of the establishment of a pro12 vider tool by a group health plan, or a health insur13 ance issuer offering group and individual health in14 surance coverage, in facilitating the provision of in15 formation made available pursuant to the amend16 ments made by subsection (a). Such report shall in17 clude the following: 

18 (A) A description of the feasibility of es19 tablishing a requirement for the various types 

20 of plans and coverage to offer such a provider 

21 tool, including any challenges to establishing a 

22 provider tool using the same technology plat23 form as the self-service tool described in such 

24 amendments. 
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1 (B) An evaluation on the usefulness of a 

2 provider tool to aid patient-decision making and 

3 how such tool would coordinate with other in4 formation available to a patient and their pro5 vider under other Federal requirements in place 

6 or under consideration. 

7 (C) An evaluation of whether the informa8 tion provided by such tool would be duplicative 

9 of the advanced explanation of benefits required 

10 under Federal law or any other existing require11 ment. 

12 (D) A description of the usability and ex13 pected utilization of such tool among providers, 

14 including among different provider types. 

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

16 tool in value-based care arrangements. 

17 (F) An analysis on the potential impact of 

18 the provider tool on— 

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

20 (ii) plan design, including impacts on 

21 cost-sharing requirements; 

22 (iii) care coordination and quality; 

23 (iv) plan premiums; 

24 (v) overall health care spending and 

25 utilization; and 
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1 (vi) health care access in rural areas. 

2 (G) An analysis of the feasibility of a pro3 vider tool to include additional functionality to 

4 facilitate and improve the administration of the 

5 requirements on providers to submit notifica6 tions to such plan or coverage under section 

7 2799B–6 of the Public Health Service Act and 

8 the requirements on such plan or coverage to 

9 provide an advanced explanation of benefits to 

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

11 Act. 

12 (H) An analysis of which health care items 

13 and services, would be most useful for patients 

14 utilizing a provider tool. 

15 (I) An analysis of rulemaking required to 

16 ensure such a tool complies with federal health 

17 information privacy standards. 

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

19 the creation of a provider tool by plans and cov20 erage on providers, issuers, employers, and 

21 other private-sector entities. 

22 (K) An analysis of the ability of state reg23 ulators to enforce provider tool standards and 

24 the costs to the Department and states to regu25 late and enforce provider tool standards. 
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1 (2) DEFINITION.—The term ‘‘provider tool’’ 

2 means a tool designed to facilitate the provision of 

3 information made available pursuant to the amend4 ments made by subsection (a) and established by a 

5 group health plan or a health insurance issuer offer6 ing group and individual health insurance coverage 

7 that allows providers to access the information such 

8 plan or coverage must provide through the self-serv9 ice tool described in such amendments to an indi10 vidual with whom the provider is actively treating at 

11 the time of such request, upon the request of the 

12 provider, and with the consent of such individual. 

13 (d) REPORTS.— 

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

15 2027, the Comptroller General of the United States 

16 shall submit to Congress a report containing— 

17 (A) an analysis of compliance with the 

18 amendments made by this section; 

19 (B) an analysis of enforcement of such 

20 amendments by the Secretaries of Health and 

21 Human Services, Labor, and the Treasury; 

22 (C) recommendations relating to improving 

23 such enforcement; and 

24 (D) recommendations relating to improving 

25 public disclosure, and public awareness, of in-
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1 formation required to be made available by 

2 group health plans and health insurance issuers 

3 pursuant to such amendments. 

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

5 and biennially thereafter, the Secretaries of Health 

6 and Human Services, Labor, and the Treasury shall 

7 jointly submit to Congress a report containing an as8 sessment of differences in negotiated prices (and any 

9 trends in such prices) in the private market be10 tween— 

11 (A) rural and urban areas; 

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

13 group markets; 

14 (C) consolidated and nonconsolidated 

15 health care provider areas (as specified by the 

16 Secretary of Health and Human Services); 

17 (D) nonprofit and for-profit hospitals; 

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

19 (F) insurers serving local or regional areas 

20 and insurers serving multistate or national 

21 areas. 

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

23 the date of enactment of this subsection, the Secretaries 

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

25 shall jointly submit to Congress a report on the feasibility 
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1 of including data relating to the quality of health care 

2 items and services with the price transparency information 

3 required to be made available under the amendments 

4 made by subsection (a). Such report shall include rec5 ommendations for legislative and regulatory actions to 

6 identify appropriate metrics for assessing and comparing 

7 quality of care. 

8 (f) CONTINUED APPLICABILITY OF RULES FOR PRE9 VIOUS YEARS.—Nothing in the amendments made by sub10 section (a) may be construed as affecting the applicability 

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

12 by the Department of the Treasury, the Department of 

13 Labor, and the Department of Health and Human Serv14 ices on November 12, 2020 (85 Fed. Reg. 72158), for any 

15 plan year beginning before January 1, 2026. 

16 SEC. 106. PHARMACY BENEFITS PRICE TRANSPARENCY. 

17 (a) PHSA.—Title XXVII of the Public Health Serv18 ice Act (42 U.S.C. 300gg et seq.) is amended— 

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

20 by adding at the end the following new section: 

21 ‘‘SEC. 2799A–11. OVERSIGHT OF PHARMACY BENEFITS MAN22 AGER SERVICES. 

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

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

25 of this section, a group health plan or a health insurance 
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1 issuer offering group health insurance coverage, or an en2 tity or subsidiary providing pharmacy benefits manage3 ment services on behalf of such a plan or issuer, shall not 

4 enter into a contract with a drug manufacturer, dis5 tributor, wholesaler, subcontractor, rebate aggregator, or 

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

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

8 the disclosure of information to group health plans in such 

9 a manner that prevents such plan, issuer, or entity from 

10 making the reports described in subsection (b). 

11 ‘‘(b) REPORTS.— 

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

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

14 the date of enactment of this section, not less fre15 quently than every 6 months (or at the request of 

16 a group health plan, not less frequently than quar17 terly, but under the same conditions, terms, and cost 

18 of the semiannual report under this subsection), a 

19 group health plan or health insurance issuer offering 

20 group health insurance coverage, or an entity pro21 viding pharmacy benefits management services on 

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

23 group health plan a report in accordance with this 

24 section. Each such report shall be made available to 

25 such group health plan in a machine-readable format 
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1 and shall include the information described in para2 graph (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) in the case of such a plan offered by 

10 a specified large employer (or such coverage of11 fered in connection with such a plan offered by 

12 a specified large employer)— 

13 ‘‘(i) a list of drugs for which a claim 

14 was filed and, with respect to each such 

15 drug on such list— 

16 ‘‘(I) the brand name, chemical 

17 entity, and National Drug Code; 

18 ‘‘(II) the type of dispensing chan19 nel used to furnish such drug, includ20 ing retail, mail order, or specialty 

21 pharmacy; 

22 ‘‘(III) with respect to each drug 

23 dispensed under each type of dis24 pensing channel (including retail, mail 

25 order, or specialty pharmacy)— 
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1 ‘‘(aa) whether such drug is a 

2 brand name drug or a generic 

3 drug, and— 

4 ‘‘(AA) in the case of a 

5 brand name drug, the whole6 sale acquisition cost, listed 

7 as cost per days supply and 

8 cost per dosage unit, on the 

9 date such drug was dis10 pensed; and 

11 ‘‘(BB) in the case of a 

12 generic drug, the average 

13 wholesale price, listed as 

14 cost per days supply and 

15 cost per dosage unit, on the 

16 date such drug was dis17 pensed; and 

18 ‘‘(bb) the total number of— 

19 ‘‘(AA) prescription 

20 claims (including original 

21 prescriptions and refills); 

22 ‘‘(BB) participants, 

23 beneficiaries, and enrollees 

24 for whom a claim for such 

25 drug was filed; 
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1 ‘‘(CC) dosage units per 

2 fill of such drug; and 

3 ‘‘(DD) days supply of 

4 such drug per fill; 

5 ‘‘(IV) the net price per course of 

6 treatment or single fill, such as a 30- 

7 day supply or 90-day supply to the 

8 plan or coverage after manufacturer 

9 rebates, fees, and other remuneration 

10 or adjustments; 

11 ‘‘(V) the total amount of out-of12 pocket spending by participants, bene13 ficiaries, and enrollees on such drug, 

14 including spending through copay15 ments, coinsurance, and deductibles; 

16 ‘‘(VI) the total net spending by 

17 the plan or coverage during the re18 porting period; 

19 ‘‘(VII) the total amount received, 

20 or expected to be received, by the plan 

21 or coverage from any entity in drug 

22 manufacturer rebates, fees, alternative 

23 discounts, and all other remuneration 

24 received from an entity or any third 

25 party (including group purchasing or-
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1 ganizations) other than the plan spon2 sor; 

3 ‘‘(VIII) the total amount re4 ceived, or expected to be received by 

5 the plan or issuer, from drug manu6 facturers in rebates, fees, alternative 

7 discounts, or other remuneration— 

8 ‘‘(aa) that has been paid, or 

9 is to be paid, by drug manufac10 turers for claims incurred during 

11 the reporting period; and 

12 ‘‘(bb) that is related to utili13 zation rebates for such drug; and 

14 ‘‘(IX) to the extent feasible, in15 formation on the total amount of re16 muneration, including copayment as17 sistance dollars paid, copayment cards 

18 applied, or other discounts provided 

19 by each drug manufacturer (or entity 

20 administering copay assistance on be21 half of such drug manufacturer) to 

22 the participants, beneficiaries, and en23 rollees enrolled in such plan or cov24 erage for such drug; 
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1 ‘‘(ii) for each category or class of 

2 drugs for which a claim was filed, a break3 down of the total gross spending on drugs 

4 in such category or class before rebates, 

5 price concessions, alternative discounts, or 

6 other remuneration from drug manufactur7 ers, and the net spending after such re8 bates, price concessions, alternative dis9 counts, or other remuneration from drug 

10 manufacturers, including— 

11 ‘‘(I) the number of participants, 

12 beneficiaries, and enrollees who filled 

13 a prescription for a drug in such cat14 egory or class, including the National 

15 Drug Code for each such drug; 

16 ‘‘(II) if applicable, a description 

17 of the formulary tiers and utilization 

18 mechanisms (such as prior authoriza19 tion or step therapy) employed for 

20 drugs in that category or class; and 

21 ‘‘(III) the total out-of-pocket 

22 spending under the plan or coverage 

23 by participants, beneficiaries, and en24 rollees, including spending through co-
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1 payments, coinsurance, and 

2 deductibles; 

3 ‘‘(iii) in the case of a drug for which 

4 gross spending by such plan, coverage, or 

5 entity exceeded $10,000 during the report6 ing period— 

7 ‘‘(I) a list of all other drugs in 

8 the same therapeutic category or 

9 class; and 

10 ‘‘(II) the rationale for the for11 mulary placement of such drug in that 

12 therapeutic category or class, if appli13 cable; and 

14 ‘‘(iv) in the case such plan or coverage 

15 (or an entity providing pharmacy benefits 

16 management services on behalf of such 

17 plan or coverage) has an affiliated phar18 macy or pharmacy under common owner19 ship— 

20 ‘‘(I) the percentage of total pre21 scriptions dispensed by such phar22 macies to individuals enrolled in such 

23 plan or coverage; 

24 ‘‘(II) a list of all drugs dispensed 

25 by such pharmacies to individuals en-
112 

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1 rolled in such plan or coverage, and, 

2 with respect to each drug dispensed— 

3 ‘‘(aa) the amount charged, 

4 per dosage unit, per 30-day sup5 ply, or per 90-day supply (as ap6 plicable) to the plan or issuer, 

7 and to participants, beneficiaries, 

8 and enrollees enrolled in such 

9 plan or coverage; 

10 ‘‘(bb) the median amount 

11 charged to such plan or issuer, 

12 and the interquartile range of the 

13 costs, per dosage unit, per 30- 

14 day supply, and per 90-day sup15 ply, including amounts paid by 

16 the participants, beneficiaries, 

17 and enrollees, when the same 

18 drug is dispensed by other phar19 macies that are not affiliated 

20 with or under common ownership 

21 with the entity and that are in22 cluded in the pharmacy network 

23 of such plan or coverage; 

24 ‘‘(cc) the lowest cost per 

25 dosage unit, per 30-day supply 
113 

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1 and per 90-day supply, for each 

2 such drug, including amounts 

3 charged to the plan and partici4 pants, beneficiaries, and enroll5 ees, that is available from any 

6 pharmacy included in the net7 work of such plan or coverage; 

8 and 

9 ‘‘(dd) the net acquisition 

10 cost per dosage unit, per 30-day 

11 supply, and per 90-day supply, if 

12 such drug is subject to a max13 imum price discount; 

14 ‘‘(B) in the case of a plan or coverage not 

15 described in subparagraph (A)— 

16 ‘‘(i) the total net spending by the plan 

17 or coverage for all drugs covered by such 

18 plan or coverage during such reporting pe19 riod; 

20 ‘‘(ii) the total amount received, or ex21 pected to be received, by the plan or cov22 erage from any entity in drug manufac23 turer rebates, fees, alternative discounts, 

24 and all other remuneration received from 

25 an entity or any third party (including 
114 

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1 group purchasing organizations) other 

2 than the plan sponsor for all such drugs; 

3 and 

4 ‘‘(iii) to the extent feasible, informa5 tion on the total amount of remuneration, 

6 including copayment assistance dollars 

7 paid, copayment cards applied, or other 

8 discounts provided by each drug manufac9 turer (or entity administering copay assist10 ance on behalf of such drug manufacturer) 

11 to the participants, beneficiaries, and en12 rollees enrolled in such plan or coverage 

13 for such drugs; 

14 ‘‘(C) amounts paid directly or indirectly in 

15 rebates, fees, or any other type of compensation 

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

17 of the Employee Retirement Income Security 

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

19 other individual or firm, for the referral of the 

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

21 business to an entity providing pharmacy bene22 fits management services, including the identity 

23 of the recipient of such amounts; 

24 ‘‘(D) an explanation of any benefit design 

25 parameters that encourage or require partici-
115 

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1 pants, beneficiaries, and enrollees in such plan 

2 or coverage to fill prescriptions at mail order, 

3 specialty, or retail pharmacies that are affili4 ated with or under common ownership with the 

5 entity providing pharmacy benefit management 

6 services under such plan or coverage, including 

7 mandatory mail and specialty home delivery 

8 programs, retail and mail auto-refill programs, 

9 and cost-sharing assistance incentives directly 

10 or indirectly funded by such entity; and 

11 ‘‘(E) total gross spending on all drugs dur12 ing the reporting period. 

13 ‘‘(3) PRIVACY REQUIREMENTS.— 

14 ‘‘(A) IN GENERAL.—Health insurance 

15 issuers offering group health insurance coverage 

16 and entities providing pharmacy benefits man17 agement services on behalf of a group health 

18 plan shall provide information under paragraph 

19 (1) in a manner consistent with the privacy, se20 curity, and breach notification regulations pro21 mulgated under section 13402(a) of the Health 

22 Information Technology for Clinical Health Act 

23 and consistent with the HIPAA privacy regula24 tions (as defined in section 1180(b)(3) of the 

25 Social Security Act) and shall restrict the use 
116 

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1 and disclosure of such information according to 

2 such privacy, security, and breach notification 

3 regulations and such HIPAA privacy regula4 tions. 

5 ‘‘(B) ADDITIONAL REQUIREMENTS.— 

6 ‘‘(i) IN GENERAL.—An entity pro7 viding pharmacy benefits management 

8 services on behalf of a group health plan or 

9 health insurance issuer offering group 

10 health insurance coverage that submits a 

11 report under paragraph (1) shall ensure 

12 that such report contains only summary 

13 health information, as defined in section 

14 164.504(a) of title 45, Code of Federal 

15 Regulations (or successor regulations). 

16 ‘‘(ii) RESTRICTIONS.—A group health 

17 plan shall comply with section 164.504(f) 

18 of title 45, Code of Federal Regulations (or 

19 a successor regulation) and a plan sponsor 

20 shall act in accordance with the terms of 

21 the agreement described in such section. 

22 ‘‘(C) RULE OF CONSTRUCTION.—Nothing 

23 in this section shall be construed to modify the 

24 requirements for the creation, receipt, mainte25 nance, or transmission of protected health in-
117 

•HR 5378 EH

1 formation under the HIPAA privacy regulations 

2 (as defined in section 1180(b)(3) of the Social 

3 Security Act). 

4 ‘‘(4) DISCLOSURE AND REDISCLOSURE.— 

5 ‘‘(A) LIMITATION TO BUSINESS ASSOCI6 ATES.—A group health plan receiving a report 

7 under paragraph (1) may disclose such informa8 tion only to the entity from which the report 

9 was received or to that entity’s business associ10 ates as defined in section 160.103 of title 45, 

11 Code of Federal Regulations (or successor regu12 lations) or as permitted by the HIPAA Privacy 

13 Rule (45 CFR parts 160 and 164, subparts A 

14 and E). 

15 ‘‘(B) CLARIFICATION REGARDING PUBLIC

16 DISCLOSURE OF INFORMATION.—Nothing in 

17 this section shall prevent a group health plan or 

18 health insurance issuer offering group health 

19 insurance coverage, or an entity providing phar20 macy benefits management services on behalf of 

21 such a plan or coverage, from placing reason22 able restrictions on the public disclosure of the 

23 information contained in a report described in 

24 paragraph (1), except that such plan, issuer, or 

25 entity may not restrict disclosure of such report 
118 

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1 to the Department of Health and Human Serv2 ices, the Department of Labor, the Department 

3 of the Treasury, or the Comptroller General of 

4 the United States. 

5 ‘‘(C) LIMITED FORM OF REPORT.—The 

6 Secretary shall define through rulemaking a 

7 limited form of the report under paragraph (1) 

8 required with respect to group health plans 

9 where the plan sponsors of such plans are drug 

10 manufacturers, drug wholesalers, or other direct 

11 participants in the drug supply chain, in order 

12 to prevent anti-competitive behavior. 

13 ‘‘(5) REPORT TO GAO.—A group health plan or 

14 health insurance issuer offering group health insur15 ance coverage, or an entity providing pharmacy ben16 efits management services on behalf of such plan or 

17 coverage, shall submit to the Comptroller General of 

18 the United States each of the first 4 reports sub19 mitted to a group health plan under paragraph (1) 

20 and other such reports as requested, in accordance 

21 with the privacy requirements under paragraph (3), 

22 the disclosure and redisclosure standards under 

23 paragraph (4), the standards specified pursuant to 

24 paragraph (6), and such other information that the 

25 Comptroller General determines necessary to carry 
119 

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1 out the study under section 106(d) of the Lower 

2 Costs, More Transparency Act. 

3 ‘‘(6) STANDARD FORMAT.—Not later than 1 

4 year after the date of enactment of this section, the 

5 Secretary shall specify through rulemaking stand6 ards for group health plans, health insurance issuers 

7 offering group health insurance coverage, and enti8 ties providing pharmacy benefits management serv9 ices on behalf of such plans or coverage, required to 

10 submit reports under paragraph (1) to submit such 

11 reports in a standard format. 

12 ‘‘(c) ENFORCEMENT.— 

13 ‘‘(1) IN GENERAL.—The Secretary shall enforce 

14 this section. 

15 ‘‘(2) FAILURE TO PROVIDE INFORMATION.—A 

16 health insurance issuer or an entity providing phar17 macy benefits management services on behalf of 

18 such plan or coverage that violates sub-section (a) or 

19 fails to provide the information required under sub20 section (b) shall be subject to a civil monetary pen21 alty in the amount of $10,000 for each day during 

22 which such violation continues or such information is 

23 not disclosed or reported. 

24 ‘‘(3) FALSE INFORMATION.—A health insurance 

25 issuer or an entity providing pharmacy benefits 
120 

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1 management services on behalf of such a plan or 

2 coverage that knowingly provides false information 

3 under this section shall be subject to a civil money 

4 penalty in an amount not to exceed $100,000 for 

5 each item of false information. Such civil money 

6 penalty shall be in addition to other penalties as 

7 may be prescribed by law. 

8 ‘‘(4) PROCEDURE.—The provisions of section 

9 1128A of the Social Security Act, other than sub10 sections (a) and (b) and the first sentence of sub11 section (c)(1) of such section shall apply to civil 

12 monetary penalties under this subsection in the 

13 same manner as such provisions apply to a penalty 

14 or proceeding under such section. 

15 ‘‘(5) WAIVERS.—The Secretary may waive pen16 alties under paragraph (2), or extend the period of 

17 time for compliance with a requirement of this sec18 tion, for an entity in violation of this section that 

19 has made a good-faith effort to comply with the re20 quirements in this section. 

21 ‘‘(d) RULE OF CONSTRUCTION.—Nothing in this sec22 tion shall be construed to permit a group health plan, 

23 health insurance issuer, or entity providing pharmacy ben24 efits management services on behalf of such plan or cov25 erage, to restrict disclosure to, or otherwise limit the ac-
121 

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1 cess of, the Department of Health and Human Services 

2 to a report described in subsection (b)(1) or information 

3 related to compliance with subsection (a) or (b) by entities 

4 subject to such subsection. 

5 ‘‘(e) DEFINITIONS.—In this section: 

6 ‘‘(1) SPECIFIED LARGE EMPLOYER.—The term 

7 ‘specified large employer’ means, in connection with 

8 a group health plan with respect to a calendar year 

9 and a plan year, an employer who employed an aver10 age of at least 50 employees on business days during 

11 the preceding calendar year and who employs at 

12 least 1 employee on the first day of the plan year. 

13 ‘‘(2) WHOLESALE ACQUISITION COST.—The 

14 term ‘wholesale acquisition cost’ has the meaning 

15 given such term in section 1847A(c)(6)(B) of the 

16 Social Security Act.’’; and 

17 (2) in section 2723 (42 U.S.C. 300gg–22)— 

18 (A) in subsection (a)— 

19 (i) in paragraph (1), by inserting 

20 ‘‘(other than subsections (a) and (b) of 

21 section 2799A–11)’’ after ‘‘part D’’; and 

22 (ii) in paragraph (2), by inserting 

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

24 section 2799A–11)’’ after ‘‘part D’’; and 

25 (B) in subsection (b)— 
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1 (i) in paragraph (1), by inserting 

2 ‘‘(other than subsections (a) and (b) of 

3 section 2799A–11)’’ after ‘‘part D’’; 

4 (ii) in paragraph (2)(A), by inserting 

5 ‘‘(other than subsections (a) and (b) of 

6 section 2799A–11)’’ after ‘‘part D’’; and 

7 (iii) in paragraph (2)(C)(ii), by insert8 ing ‘‘(other than subsections (a) and (b) of 

9 section 2799A–11)’’ after ‘‘part D’’. 

10 (b) ERISA.— 

11 (1) IN GENERAL.—Subtitle B of title I of the 

12 Employee Retirement Income Security Act of 1974 

13 (29 U.S.C. 1021 et seq.) is amended— 

14 (A) in subpart B of part 7 (29 U.S.C. 

15 1185 et seq.), by adding at the end the fol16 lowing: 

17 ‘‘SEC. 726. OVERSIGHT OF PHARMACY BENEFIT MANAGER 

18 SERVICES. 

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

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

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

22 issuer offering group health insurance coverage, or an en23 tity or subsidiary providing pharmacy benefits manage24 ment services on behalf of such a plan or issuer, shall not 

25 enter into a contract with a drug manufacturer, dis-
123 

•HR 5378 EH

1 tributor, wholesaler, subcontractor, rebate aggregator, or 

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

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

4 the disclosure of information to group health plans in such 

5 a manner that prevents such plan, issuer, or entity from 

6 making the reports described in subsection (b). 

7 ‘‘(b) REPORTS.— 

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

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

10 the date of enactment of this section, not less fre11 quently than every 6 months (or at the request of 

12 a group health plan, not less frequently than quar13 terly, but under the same conditions, terms, and cost 

14 of the semiannual report under this subsection), a 

15 group health plan or health insurance issuer offering 

16 group health insurance coverage, or an entity pro17 viding pharmacy benefits management services on 

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

19 group health plan a report in accordance with this 

20 section. Each such report shall be made available to 

21 such group health plan in a machine-readable format 

22 and shall include the information described in para23 graph (2). 

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

25 of paragraph (1), the information described in this 
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1 paragraph is, with respect to drugs covered by a 

2 group health plan or health insurance issuer offering 

3 group health insurance coverage during each report4 ing period— 

5 ‘‘(A) in the case of such a plan offered by 

6 a specified large employer (or such coverage of7 fered in connection with such a plan offered by 

8 a specified large employer)— 

9 ‘‘(i) a list of drugs for which a claim 

10 was filed and, with respect to each such 

11 drug on such list— 

12 ‘‘(I) the brand name, chemical 

13 entity, and National Drug Code; 

14 ‘‘(II) the type of dispensing chan15 nel used to furnish such drug, includ16 ing retail, mail order, or specialty 

17 pharmacy; 

18 ‘‘(III) with respect to each drug 

19 dispensed under each type of dis20 pensing channel (including retail, mail 

21 order, or specialty pharmacy)— 

22 ‘‘(aa) whether such drug is a 

23 brand name drug or a generic 

24 drug, and— 
125 

•HR 5378 EH

1 ‘‘(AA) in the case of a 

2 brand name drug, the whole3 sale acquisition cost, listed 

4 as cost per days supply and 

5 cost per dosage unit, on the 

6 date such drug was dis7 pensed; and 

8 ‘‘(BB) in the case of a 

9 generic drug, the average 

10 wholesale price, listed as 

11 cost per days supply and 

12 cost per dosage unit, on the 

13 date such drug was dis14 pensed; and 

15 ‘‘(bb) the total number of— 

16 ‘‘(AA) prescription 

17 claims (including original 

18 prescriptions and refills); 

19 ‘‘(BB) participants and 

20 beneficiaries for whom a 

21 claim for such drug was 

22 filed; 

23 ‘‘(CC) dosage units per 

24 fill of such drug; and 
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1 ‘‘(DD) days supply of 

2 such drug per fill; 

3 ‘‘(IV) the net price per course of 

4 treatment or single fill, such as a 30- 

5 day supply or 90-day supply to the 

6 plan or coverage after manufacturer 

7 rebates, fees, and other remuneration 

8 or adjustments; 

9 ‘‘(V) the total amount of out-of10 pocket spending by participants, bene11 ficiaries, and enrollees on such drug, 

12 including spending through copay13 ments, coinsurance, and deductibles; 

14 ‘‘(VI) the total net spending by 

15 the plan or coverage during the re16 porting period; 

17 ‘‘(VII) the total amount received, 

18 or expected to be received, by the plan 

19 or coverage from any entity in drug 

20 manufacturer rebates, fees, alternative 

21 discounts, and all other remuneration 

22 received from an entity or any third 

23 party (including group purchasing or24 ganizations) other than the plan spon25 sor; 
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•HR 5378 EH

1 ‘‘(VIII) the total amount re2 ceived, or expected to be received by 

3 the plan or issuer, from drug manu4 facturers in rebates, fees, alternative 

5 discounts, or other remuneration— 

6 ‘‘(aa) that has been paid, or 

7 is to be paid, by drug manufac8 turers for claims incurred during 

9 the reporting period; and 

10 ‘‘(bb) that is related to utili11 zation rebates for such drug; and 

12 ‘‘(IX) to the extent feasible, in13 formation on the total amount of re14 muneration, including copayment as15 sistance dollars paid, copayment cards 

16 applied, or other discounts provided 

17 by each drug manufacturer (or entity 

18 administering copay assistance on be19 half of such drug manufacturer) to 

20 the participants, beneficiaries, and en21 rollees enrolled in such plan or cov22 erage for such drug; 

23 ‘‘(ii) for each category or class of 

24 drugs for which a claim was filed, a break25 down of the total gross spending on drugs 
128 

•HR 5378 EH

1 in such category or class before rebates, 

2 price concessions, alternative discounts, or 

3 other remuneration from drug manufactur4 ers, and the net spending after such re5 bates, price concessions, alternative dis6 counts, or other remuneration from drug 

7 manufacturers, including— 

8 ‘‘(I) the number of participants, 

9 beneficiaries, and enrollees who filled 

10 a prescription for a drug in such cat11 egory or class, including the National 

12 Drug Code for each such drug; 

13 ‘‘(II) if applicable, a description 

14 of the formulary tiers and utilization 

15 mechanisms (such as prior authoriza16 tion or step therapy) employed for 

17 drugs in that category or class; and 

18 ‘‘(III) the total out-of-pocket 

19 spending under the plan or coverage 

20 by participants, beneficiaries, and en21 rollees, including spending through co22 payments, coinsurance, and 

23 deductibles; 

24 ‘‘(iii) in the case of a drug for which 

25 gross spending by such plan, coverage, or 
129 

•HR 5378 EH

1 entity exceeded $10,000 during the report2 ing period— 

3 ‘‘(I) a list of all other drugs in 

4 the same therapeutic category or 

5 class; and 

6 ‘‘(II) the rationale for the for7 mulary placement of such drug in that 

8 therapeutic category or class, if appli9 cable; and 

10 ‘‘(iv) in the case such plan or coverage 

11 (or an entity providing pharmacy benefits 

12 management services on behalf of such 

13 plan or coverage) has an affiliated phar14 macy or pharmacy under common owner15 ship— 

16 ‘‘(I) the percentage of total pre17 scriptions dispensed by such phar18 macies to individuals enrolled in such 

19 plan or coverage; 

20 ‘‘(II) a list of all drugs dispensed 

21 by such pharmacies to individuals en22 rolled in such plan or coverage, and, 

23 with respect to each drug dispensed— 

24 ‘‘(aa) the amount charged, 

25 per dosage unit, per 30-day sup-
130 

•HR 5378 EH

1 ply, or per 90-day supply (as ap2 plicable) to the plan or issuer, 

3 and to participants, beneficiaries, 

4 and enrollees enrolled in such 

5 plan or coverage; 

6 ‘‘(bb) the median amount 

7 charged to such plan or issuer, 

8 and the interquartile range of the 

9 costs, per dosage unit, per 30- 

10 day supply, and per 90-day sup11 ply, including amounts paid by 

12 the participants, beneficiaries, 

13 and enrollees, when the same 

14 drug is dispensed by other phar15 macies that are not affiliated 

16 with or under common ownership 

17 with the entity and that are in18 cluded in the pharmacy network 

19 of such plan or coverage; 

20 ‘‘(cc) the lowest cost per 

21 dosage unit, per 30-day supply 

22 and per 90-day supply, for each 

23 such drug, including amounts 

24 charged to the plan and partici25 pants, beneficiaries, and enroll-
131 

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1 ees, that is available from any 

2 pharmacy included in the net3 work of such plan or coverage; 

4 and 

5 ‘‘(dd) the net acquisition 

6 cost per dosage unit, per 30-day 

7 supply, and per 90-day supply, if 

8 such drug is subject to a max9 imum price discount; 

10 ‘‘(B) in the case of a plan or coverage not 

11 described in subparagraph (A)— 

12 ‘‘(i) the total net spending by the plan 

13 or coverage for all drugs covered by such 

14 plan or coverage during such reporting pe15 riod; 

16 ‘‘(ii) the total amount received, or ex17 pected to be received, by the plan or cov18 erage from any entity in drug manufac19 turer rebates, fees, alternative discounts, 

20 and all other remuneration received from 

21 an entity or any third party (including 

22 group purchasing organizations) other 

23 than the plan sponsor for all such drugs; 

24 and 
132 

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1 ‘‘(iii) to the extent feasible, informa2 tion on the total amount of remuneration, 

3 including copayment assistance dollars 

4 paid, copayment cards applied, or other 

5 discounts provided by each drug manufac6 turer (or entity administering copay assist7 ance on behalf of such drug manufacturer) 

8 to the participants, beneficiaries, and en9 rollees enrolled in such plan or coverage 

10 for such drugs; 

11 ‘‘(C) amounts paid directly or indirectly in 

12 rebates, fees, or any other type of compensation 

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

14 to brokers, consultants, advisors, or any other 

15 individual or firm, for the referral of the group 

16 health plan’s or health insurance issuer’s busi17 ness to an entity providing pharmacy benefits 

18 management services, including the identity of 

19 the recipient of such amounts; 

20 ‘‘(D) an explanation of any benefit design 

21 parameters that encourage or require partici22 pants, beneficiaries, and enrollees in such plan 

23 or coverage to fill prescriptions at mail order, 

24 specialty, or retail pharmacies that are affili25 ated with or under common ownership with the 
133 

•HR 5378 EH

1 entity providing pharmacy benefit management 

2 services under such plan or coverage, including 

3 mandatory mail and specialty home delivery 

4 programs, retail and mail auto-refill programs, 

5 and cost-sharing assistance incentives directly 

6 or indirectly funded by such entity; and 

7 ‘‘(E) total gross spending on all drugs dur8 ing the reporting period. 

9 ‘‘(3) PRIVACY REQUIREMENTS.— 

10 ‘‘(A) IN GENERAL.—Health insurance 

11 issuers offering group health insurance coverage 

12 and entities providing pharmacy benefits man13 agement services on behalf of a group health 

14 plan shall provide information under paragraph 

15 (1) in a manner consistent with the privacy, se16 curity, and breach notification regulations pro17 mulgated under section 13402(a) of the Health 

18 Information Technology for Clinical Health Act 

19 and consistent with the HIPAA privacy regula20 tions (as defined in section 1180(b)(3) of the 

21 Social Security Act) and shall restrict the use 

22 and disclosure of such information according to 

23 such privacy, security, and breach notification 

24 regulations and such HIPAA privacy regula25 tions. 
134 

•HR 5378 EH

1 ‘‘(B) ADDITIONAL REQUIREMENTS.— 

2 ‘‘(i) IN GENERAL.—An entity pro3 viding pharmacy benefits management 

4 services on behalf of a group health plan or 

5 health insurance issuer offering group 

6 health insurance coverage that submits a 

7 report under paragraph (1) shall ensure 

8 that such report contains only summary 

9 health information, as defined in section 

10 164.504(a) of title 45, Code of Federal 

11 Regulations (or successor regulations). 

12 ‘‘(ii) RESTRICTIONS.—A group health 

13 plan shall comply with section 164.504(f) 

14 of title 45, Code of Federal Regulations (or 

15 a successor regulation) and a plan sponsor 

16 shall act in accordance with the terms of 

17 the agreement described in such section. 

18 ‘‘(C) RULE OF CONSTRUCTION.—Nothing 

19 in this section shall be construed to modify the 

20 requirements for the creation, receipt, mainte21 nance, or transmission of protected health in22 formation under the HIPAA privacy regulations 

23 (as defined in section 1180(b)(3) of the Social 

24 Security Act). 

25 ‘‘(4) DISCLOSURE AND REDISCLOSURE.— 
135 

•HR 5378 EH

1 ‘‘(A) LIMITATION TO BUSINESS ASSOCI2 ATES.—A group health plan receiving a report 

3 under paragraph (1) may disclose such informa4 tion only to the entity from which the report 

5 was received or to that entity’s business associ6 ates as defined in section 160.103 of title 45, 

7 Code of Federal Regulations (or successor regu8 lations) or as permitted by the HIPAA Privacy 

9 Rule (45 CFR parts 160 and 164, subparts A 

10 and E). 

11 ‘‘(B) CLARIFICATION REGARDING PUBLIC

12 DISCLOSURE OF INFORMATION.—Nothing in 

13 this section shall prevent a group health plan or 

14 health insurance issuer offering group health 

15 insurance coverage, or an entity providing phar16 macy benefits management services on behalf of 

17 such a plan or coverage, from placing reason18 able restrictions on the public disclosure of the 

19 information contained in a report described in 

20 paragraph (1), except that such plan, issuer, or 

21 entity may not restrict disclosure of such report 

22 to the Department of Health and Human Serv23 ices, the Department of Labor, the Department 

24 of the Treasury, or the Comptroller General of 

25 the United States. 
136 

•HR 5378 EH

1 ‘‘(C) LIMITED FORM OF REPORT.—The 

2 Secretary shall define through rulemaking a 

3 limited form of the report under paragraph (1) 

4 required with respect to group health plans 

5 where the plan sponsors of such plans are drug 

6 manufacturers, drug wholesalers, or other direct 

7 participants in the drug supply chain, in order 

8 to prevent anti-competitive behavior. 

9 ‘‘(5) REPORT TO GAO.—A group health plan or 

10 health insurance issuer offering group health insur11 ance coverage, or an entity providing pharmacy ben12 efits management services on behalf of such plan or 

13 coverage, shall submit to the Comptroller General of 

14 the United States each of the first 4 reports sub15 mitted to a group health plan under paragraph (1) 

16 and other such reports as requested, in accordance 

17 with the privacy requirements under paragraph (3), 

18 the disclosure and redisclosure standards under 

19 paragraph (4), the standards specified pursuant to 

20 paragraph (6), and such other information that the 

21 Comptroller General determines necessary to carry 

22 out the study under section 106(d) of the Lower 

23 Costs, More Transparency Act. 

24 ‘‘(6) STANDARD FORMAT.—Not later than 1 

25 year after the date of enactment of this section, the 
137 

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1 Secretary shall specify through rulemaking stand2 ards for group health plans, health insurance issuers 

3 offering group health insurance coverage, and enti4 ties providing pharmacy benefits management serv5 ices on behalf of such plans or coverage, required to 

6 submit reports under paragraph (1) to submit such 

7 reports in a standard format. 

8 ‘‘(c) RULE OF CONSTRUCTION.—Nothing in this sec9 tion shall be construed to permit a group health plan, 

10 health insurance issuer, or entity providing pharmacy ben11 efits management services on behalf of such plan or cov12 erage, to restrict disclosure to, or otherwise limit the ac13 cess of, the Secretary of Labor to a report described in 

14 subsection (b)(1) or information related to compliance 

15 with subsection (a) or (b) by entities subject to such sub16 section. 

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

18 ‘‘(1) SPECIFIED LARGE EMPLOYER.—The term 

19 ‘specified large employer’ means, in connection with 

20 a group health plan with respect to a calendar year 

21 and a plan year, an employer who employed an aver22 age of at least 50 employees on business days during 

23 the preceding calendar year and who employs at 

24 least 1 employee on the first day of the plan year. 
138 

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1 ‘‘(2) WHOLESALE ACQUISITION COST.—The 

2 term ‘wholesale acquisition cost’ has the meaning 

3 given such term in section 1847A(c)(6)(B) of the 

4 Social Security Act.’’. 

5 (B) in section 502 (29 U.S.C. 1132)— 

6 (i) in subsection (b)(3), by striking 

7 ‘‘under subsection (c)(9))’’ and inserting 

8 ‘‘under paragraphs (9) and (13) of sub9 section (c))’’; and 

10 (ii) in subsection (c), by adding at the 

11 end the following new paragraph: 

12 ‘‘(13) SECRETARIAL ENFORCEMENT AUTHORITY

13 RELATING TO OVERSIGHT OF PHARMACY BENEFITS

14 MANAGER SERVICES.— 

15 ‘‘(A) FAILURE TO PROVIDE INFORMA16 TION.—The Secretary may impose a penalty 

17 against any health insurance issuer or entity 

18 providing pharmacy benefits management serv19 ices that violates section 726(a) or fails to pro20 vide information required under section 726(b) 

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

22 which such violation continues or such informa23 tion is not disclosed or reported. 

24 ‘‘(B) FALSE INFORMATION.—The Sec25 retary may impose a penalty against a health 
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1 insurance issuer or entity providing pharmacy 

2 benefits management services that knowingly 

3 provides false information under section 726 in 

4 an amount not to exceed $100,000 for each 

5 item of false information. Such penalty shall be 

6 in addition to other penalties as may be pre7 scribed by law. 

8 ‘‘(C) WAIVERS.—The Secretary may waive 

9 penalties under subparagraph (A), or extend 

10 the period of time for compliance with a re11 quirement of section 726, for an entity in viola12 tion of such section that has made a good-faith 

13 effort to comply with such section.’’. 

14 (2) CLERICAL AMENDMENT.—The table of con15 tents in section 1 of the Employee Retirement In16 come Security Act of 1974 (29 U.S.C. 1001 et seq.) 

17 is amended by inserting after the item relating to 

18 section 725 the following new item: 

‘‘Sec. 726. Oversight of pharmacy benefits manager services.’’. 

19 (c) IRC.— 

20 (1) IN GENERAL.—Subchapter B of chapter 

21 100 of the Internal Revenue Code of 1986 is amend22 ed by adding at the end the following: 
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1 ‘‘SEC. 9826. 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 an entity or sub6 sidiary providing pharmacy benefits management services 

7 on behalf of such a plan, shall not enter into a contract 

8 with a drug manufacturer, distributor, wholesaler, subcon9 tractor, rebate aggregator, or any other third party that 

10 limits (or delays beyond the applicable reporting period de11 scribed in subsection (b)(1)) the disclosure of information 

12 to group health plans in such a manner that prevents such 

13 plan or entity from making the reports described in sub14 section (b). 

15 ‘‘(b) REPORTS.— 

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

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

18 the date of enactment of this section, not less fre19 quently than every 6 months (or at the request of 

20 a group health plan, not less frequently than quar21 terly, but under the same conditions, terms, and cost 

22 of the semiannual report under this subsection), a 

23 group health plan, or an entity providing pharmacy 

24 benefits management services on behalf of such a 

25 plan, shall submit to the group health plan a report 

26 in accordance with this section. Each such report 
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1 shall be made available to such group health plan in 

2 a machine-readable format and shall include the in3 formation described in paragraph (2). 

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

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

6 paragraph is, with respect to drugs covered by a 

7 group health plan during each reporting period— 

8 ‘‘(A) in the case of such a plan offered by 

9 a specified large employer— 

10 ‘‘(i) a list of drugs for which a claim 

11 was filed and, with respect to each such 

12 drug on such list— 

13 ‘‘(I) the brand name, chemical 

14 entity, and National Drug Code; 

15 ‘‘(II) the type of dispensing chan16 nel used to furnish such drug, includ17 ing retail, mail order, or specialty 

18 pharmacy; 

19 ‘‘(III) with respect to each drug 

20 dispensed under each type of dis21 pensing channel (including retail, mail 

22 order, or specialty pharmacy)— 

23 ‘‘(aa) whether such drug is a 

24 brand name drug or a generic 

25 drug, and— 
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1 ‘‘(AA) in the case of a 

2 brand name drug, the whole3 sale acquisition cost, listed 

4 as cost per days supply and 

5 cost per dosage unit, on the 

6 date such drug was dis7 pensed; and 

8 ‘‘(BB) in the case of a 

9 generic drug, the average 

10 wholesale price, listed as 

11 cost per days supply and 

12 cost per dosage unit, on the 

13 date such drug was dis14 pensed; and 

15 ‘‘(bb) the total number of— 

16 ‘‘(AA) prescription 

17 claims (including original 

18 prescriptions and refills); 

19 ‘‘(BB) participants, 

20 beneficiaries, and enrollees 

21 for whom a claim for such 

22 drug was filed; 

23 ‘‘(CC) dosage units per 

24 fill of such drug; and 
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1 ‘‘(DD) days supply of 

2 such drug per fill; 

3 ‘‘(IV) the net price per course of 

4 treatment or single fill, such as a 30- 

5 day supply or 90-day supply to the 

6 plan after manufacturer rebates, fees, 

7 and other remuneration or adjust8 ments; 

9 ‘‘(V) the total amount of out-of10 pocket spending by participants, bene11 ficiaries, and enrollees on such drug, 

12 including spending through copay13 ments, coinsurance, and deductibles; 

14 ‘‘(VI) the total net spending by 

15 the plan during the reporting period; 

16 ‘‘(VII) the total amount received, 

17 or expected to be received, by the plan 

18 from any entity in drug manufacturer 

19 rebates, fees, alternative discounts, 

20 and all other remuneration received 

21 from an entity or any third party (in22 cluding group purchasing organiza23 tions) other than the plan sponsor; 

24 ‘‘(VIII) the total amount re25 ceived, or expected to be received by 
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1 the plan, from drug manufacturers in 

2 rebates, fees, alternative discounts, or 

3 other remuneration— 

4 ‘‘(aa) that has been paid, or 

5 is to be paid, by drug manufac6 turers for claims incurred during 

7 the reporting period; and 

8 ‘‘(bb) that is related to utili9 zation rebates for such drug; and 

10 ‘‘(IX) to the extent feasible, in11 formation on the total amount of re12 muneration, including copayment as13 sistance dollars paid, copayment cards 

14 applied, or other discounts provided 

15 by each drug manufacturer (or entity 

16 administering copay assistance on be17 half of such drug manufacturer) to 

18 the participants, beneficiaries, and en19 rollees enrolled in such plan for such 

20 drug; 

21 ‘‘(ii) for each category or class of 

22 drugs for which a claim was filed, a break23 down of the total gross spending on drugs 

24 in such category or class before rebates, 

25 price concessions, alternative discounts, or 
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1 other remuneration from drug manufactur2 ers, and the net spending after such re3 bates, price concessions, alternative dis4 counts, or other remuneration from drug 

5 manufacturers, including— 

6 ‘‘(I) the number of participants, 

7 beneficiaries, and enrollees who filled 

8 a prescription for a drug in such cat9 egory or class, including the National 

10 Drug Code for each such drug; 

11 ‘‘(II) if applicable, a description 

12 of the formulary tiers and utilization 

13 mechanisms (such as prior authoriza14 tion or step therapy) employed for 

15 drugs in that category or class; 

16 ‘‘(III) the total out-of-pocket 

17 spending under the plan by partici18 pants, beneficiaries, and enrollees, in19 cluding spending through copayments, 

20 coinsurance, and deductibles; and 

21 ‘‘(iii) in the case of a drug for which 

22 gross spending by such plan or entity ex23 ceeded $10,000 during the reporting pe24 riod— 
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1 ‘‘(I) a list of all other drugs in 

2 the same therapeutic category or 

3 class; and 

4 ‘‘(II) the rationale for the for5 mulary placement of such drug in that 

6 therapeutic category or class, if appli7 cable; and 

8 ‘‘(iv) in the case such plan (or an en9 tity providing pharmacy benefits manage10 ment services on behalf of such plan) that 

11 has an affiliated pharmacy or pharmacy 

12 under common ownership— 

13 ‘‘(I) the percentage of total pre14 scriptions dispensed by such phar15 macies to individuals enrolled in such 

16 plan; 

17 ‘‘(II) a list of all drugs dispensed 

18 by such pharmacies to individuals en19 rolled in such plan, and, with respect 

20 to each drug dispensed— 

21 ‘‘(aa) the amount charged, 

22 per dosage unit, per 30-day sup23 ply, or per 90-day supply (as ap24 plicable) to the plan, and to par-
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1 ticipants, beneficiaries, and en2 rollees enrolled in such plan; 

3 ‘‘(bb) the median amount 

4 charged to such plan, and the 

5 interquartile range of the costs, 

6 per dosage unit, per 30-day sup7 ply, and per 90-day supply, in8 cluding amounts paid by the par9 ticipants, beneficiaries, and en10 rollees, when the same drug is 

11 dispensed by other pharmacies 

12 that are not affiliated with or 

13 under common ownership with 

14 the entity and that are included 

15 in the pharmacy network of such 

16 plan; 

17 ‘‘(cc) the lowest cost per 

18 dosage unit, per 30-day supply 

19 and per 90-day supply, for each 

20 such drug, including amounts 

21 charged to the plan and partici22 pants, beneficiaries, and enroll23 ees, that is available from any 

24 pharmacy included in the net25 work of such plan; and 
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1 ‘‘(dd) the net acquisition 

2 cost per dosage unit, per 30-day 

3 supply, and per 90-day supply, if 

4 such drug is subject to a max5 imum price discount; 

6 ‘‘(B) in the case of a plan not described in 

7 subparagraph (A)— 

8 ‘‘(i) the total net spending by the plan 

9 for all drugs covered by such plan during 

10 such reporting period; 

11 ‘‘(ii) the total amount received, or ex12 pected to be received, by the plan from any 

13 entity in drug manufacturer rebates, fees, 

14 alternative discounts, and all other remu15 neration received from an entity or any 

16 third party (including group purchasing or17 ganizations) other than the plan sponsor 

18 for all such drugs; and 

19 ‘‘(iii) to the extent feasible, informa20 tion on the total amount of remuneration, 

21 including copayment assistance dollars 

22 paid, copayment cards applied, or other 

23 discounts provided by each drug manufac24 turer (or entity administering copay assist25 ance on behalf of such drug manufacturer) 
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1 to the participants, beneficiaries, and en2 rollees enrolled in such plan for such 

3 drugs; 

4 ‘‘(C) amounts paid directly or indirectly in 

5 rebates, fees, or any other type of compensation 

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

7 of the Employee Retirement Income Security 

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

9 other individual or firm, for the referral of the 

10 group health plan’s business to an entity pro11 viding pharmacy benefits management services, 

12 including the identity of the recipient of such 

13 amounts; 

14 ‘‘(D) an explanation of any benefit design 

15 parameters that encourage or require partici16 pants, beneficiaries, and enrollees in such plan 

17 to fill prescriptions at mail order, specialty, or 

18 retail pharmacies that are affiliated with or 

19 under common ownership with the entity pro20 viding pharmacy benefit management services 

21 under such plan, including mandatory mail and 

22 specialty home delivery programs, retail and 

23 mail auto-refill programs, and cost-sharing as24 sistance incentives directly or indirectly funded 

25 by such entity; and 
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1 ‘‘(E) total gross spending on all drugs dur2 ing the reporting period. 

3 ‘‘(3) PRIVACY REQUIREMENTS.— 

4 ‘‘(A) IN GENERAL.—Entities providing 

5 pharmacy benefits management services on be6 half of a group health plan shall provide infor7 mation under paragraph (1) in a manner con8 sistent with the privacy, security, and breach 

9 notification regulations promulgated under sec10 tion 13402(a) of the Health Information Tech11 nology for Clinical Health Act and consistent 

12 with the HIPAA privacy regulations (as defined 

13 in section 1180(b)(3) of the Social Security 

14 Act) and shall restrict the use and disclosure of 

15 such information according to such privacy, se16 curity, and breach notification regulations and 

17 such HIPAA privacy regulations. 

18 ‘‘(B) ADDITIONAL REQUIREMENTS.— 

19 ‘‘(i) IN GENERAL.—An entity pro20 viding pharmacy benefits management 

21 services on behalf of a group health plan 

22 that submits a report under paragraph (1) 

23 shall ensure that such report contains only 

24 summary health information, as defined in 

25 section 164.504(a) of title 45, Code of 
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1 Federal Regulations (or successor regula2 tions). 

3 ‘‘(ii) RESTRICTIONS.—A group health 

4 plan shall comply with section 164.504(f) 

5 of title 45, Code of Federal Regulations (or 

6 a successor regulation) and a plan sponsor 

7 shall act in accordance with the terms of 

8 the agreement described in such section. 

9 ‘‘(C) RULE OF CONSTRUCTION.—Nothing 

10 in this section shall be construed to modify the 

11 requirements for the creation, receipt, mainte12 nance, or transmission of protected health in13 formation under the HIPAA privacy regulations 

14 (as defined in section 1180(b)(3) of the Social 

15 Security Act). 

16 ‘‘(4) DISCLOSURE AND REDISCLOSURE.— 

17 ‘‘(A) LIMITATION TO BUSINESS ASSOCI18 ATES.—A group health plan receiving a report 

19 under paragraph (1) may disclose such informa20 tion only to the entity from which the report 

21 was received or to that entity’s business associ22 ates as defined in section 160.103 of title 45, 

23 Code of Federal Regulations (or successor regu24 lations) or as permitted by the HIPAA Privacy 
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1 Rule (45 CFR parts 160 and 164, subparts A 

2 and E). 

3 ‘‘(B) CLARIFICATION REGARDING PUBLIC

4 DISCLOSURE OF INFORMATION.—Nothing in 

5 this section shall prevent a group health plan or 

6 health insurance issuer offering group health 

7 insurance coverage, or an entity providing phar8 macy benefits management services on behalf of 

9 such a plan or coverage, from placing reason10 able restrictions on the public disclosure of the 

11 information contained in a report described in 

12 paragraph (1), except that such plan, issuer, or 

13 entity may not restrict disclosure of such report 

14 to the Department of Health and Human Serv15 ices, the Department of Labor, the Department 

16 of the Treasury, or the Comptroller General of 

17 the United States. 

18 ‘‘(C) LIMITED FORM OF REPORT.—The 

19 Secretary shall define through rulemaking a 

20 limited form of the report under paragraph (1) 

21 required with respect to group health plans 

22 where the plan sponsors of such plans are drug 

23 manufacturers, drug wholesalers, or other direct 

24 participants in the drug supply chain, in order 

25 to prevent anti-competitive behavior. 
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1 ‘‘(5) REPORT TO GAO.—A group health plan, or 

2 an entity providing pharmacy benefits management 

3 services on behalf of such plan, shall submit to the 

4 Comptroller General of the United States each of 

5 the first 4 reports submitted to a group health plan 

6 under paragraph (1) and other such reports as re7 quested, in accordance with the privacy requirements 

8 under paragraph (3), the disclosure and redisclosure 

9 standards under paragraph (4), the standards speci10 fied pursuant to paragraph (6), and such other in11 formation that the Comptroller General determines 

12 necessary to carry out the study under section 

13 106(d) of the Lower Costs, More Transparency Act. 

14 ‘‘(6) STANDARD FORMAT.—Not later than 1 

15 year after the date of enactment of this section, the 

16 Secretary shall specify through rulemaking stand17 ards for group health plans, and entities providing 

18 pharmacy benefits management services on behalf of 

19 such plans, required to submit reports under para20 graph (1) to submit such reports in a standard for21 mat. 

22 ‘‘(c) RULE OF CONSTRUCTION.—Nothing in this sec23 tion shall be construed to permit a group health plan or 

24 entity providing pharmacy benefits management services 

25 on behalf of such plan, to restrict disclosure to, or other-
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1 wise limit the access of, the Secretary of Health and 

2 Human Services to a report described in subsection (b)(1) 

3 or information related to compliance with subsections (a) 

4 or (b) by entities subject to such subsection. 

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

6 ‘‘(1) SPECIFIED LARGE EMPLOYER.—The term 

7 ‘specified large employer’ means, in connection with 

8 a group health plan with respect to a calendar year 

9 and a plan year, an employer who employed an aver10 age of at least 50 employees on business days during 

11 the preceding calendar year and who employs at 

12 least 1 employee on the first day of the plan year. 

13 ‘‘(2) WHOLESALE ACQUISITION COST.—The 

14 term ‘wholesale acquisition cost’ has the meaning 

15 given such term in section 1847A(c)(6)(B) of the 

16 Social Security Act.’’. 

17 (2) CLERICAL AMENDMENT.—The table of sec18 tions for subchapter B of chapter 100 of the Inter19 nal Revenue Code of 1986 is amended by adding at 

20 the end the following new item: 

‘‘Sec. 9826. Oversight of pharmacy benefits manager services.’’. 

21 (d) GAO REPORTS.— 

22 (1) REPORT ON PHARMACY NETWORK DE23 SIGN.— 

24 (A) IN GENERAL.—Not later than 3 years 

25 after the date of enactment of this Act, the 
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1 Comptroller General of the United States shall 

2 submit to Congress a report on— 

3 (i) pharmacy networks that have con4 tracted with group health plans, health in5 surance issuers offering group health in6 surance coverage, or entities providing 

7 pharmacy benefits management services on 

8 behalf of such plans or issuers, including 

9 networks with pharmacies that are under 

10 common ownership (in whole or part) with 

11 such plans, issuers, or entities (including 

12 entities that provide pharmacy benefits ad13 ministrative services on behalf of such 

14 plans or issuers); 

15 (ii) pharmacy network design param16 eters that encourage individuals enrolled in 

17 such plans or coverage to fill prescriptions 

18 at mail order, specialty, or retail phar19 macies that are wholly or partially owned 

20 by a plan, issuer, or entity; 

21 (iii) whether such plans and issuers 

22 have options to elect different network 

23 pricing arrangements in the marketplace 

24 with entities that provide pharmacy bene25 fits management services and the preva-
156 

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1 lence of electing such different network 

2 pricing arrangements; 

3 (iv) with respect to pharmacy net4 works that include pharmacies under com5 mon ownership described in clause (i)— 

6 (I) whether such networks are 

7 designed to encourage individuals en8 rolled in a group health plan or health 

9 insurance coverage to use such phar10 macies over other network pharmacies 

11 for specific services or drugs, and if 

12 so, the reasons the networks give for 

13 encouraging use of such pharmacies; 

14 and 

15 (II) whether such pharmacies are 

16 used by enrollees disproportionately 

17 more in the aggregate or for specific 

18 services or drugs compared to other 

19 network pharmacies; 

20 (v) the degree to which mail order, 

21 specialty, or retail pharmacies that dis22 pense prescription drugs to an enrollee in 

23 a plan or coverage that are under common 

24 ownership (in whole or part) with plans, 

25 issuers, or entities providing pharmacy 
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1 benefits management services or pharmacy 

2 benefits administrative services on behalf 

3 of such plan or coverage receive reimburse4 ment that is greater than the median price 

5 charged to the plan or issuer when the 

6 same drug is dispensed to enrollees in the 

7 plan or coverage by other pharmacies in8 cluded in the pharmacy network of that 

9 plan, issuer, or entity that are not wholly 

10 or partially owned by the plan or issuer, or 

11 entity providing pharmacy benefits man12 agement services on behalf of such plan or 

13 issuer. 

14 (B) REQUIREMENT.—The Comptroller 

15 General of the United States shall ensure that 

16 the report under subparagraph (A) does not 

17 contain information that would identify a spe18 cific group health plan or health insurance 

19 issuer (or an entity providing pharmacy benefits 

20 management services on behalf of such plan or 

21 issuer), or otherwise contain commercial or fi22 nancial information that is privileged or con23 fidential. 

24 (C) DEFINITIONS.—In this paragraph, the 

25 terms ‘‘group health plan’’, ‘‘health insurance 
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1 coverage’’, and ‘‘health insurance issuer’’ have 

2 the meanings given such terms in section 2791 

3 of the Public Health Service Act (42 U.S.C. 

4 300gg–91). 

5 (2) REPORT ON COPAY ASSISTANCE PRO6 GRAMS.—Not later than 18 months after the date of 

7 the enactment of this Act, the Comptroller General 

8 of the United States shall submit to Congress a re9 port on what is known about the role of copay as10 sistance programs and the impact of such programs 

11 on commercial health insurance, stop loss, and drug 

12 prices. Such report shall include to the extent fea13 sible— 

14 (A) a description of copay assistance pro15 grams, including— 

16 (i) the types of programs available 

17 and the methods of providing copay assist18 ance through such programs, including 

19 cash discounts, copay cards, or drugs pro20 vided to an individual at no cost; 

21 (ii) how such programs are funded; 

22 (iii) the types of entities that own, op23 erate, or otherwise conduct such programs, 

24 the types of information such entities col25 lect, and the direct and indirect contrac-
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1 tual relationships between the entities in 

2 the drug supply chain that interact with 

3 such programs, such as a drug manufac4 turer, pharmacy, wholesaler, switch, rebate 

5 aggregator, pharmacy benefit manager, 

6 and other entities in the drug supply chain; 

7 (iv) the effect of such programs on 

8 patient out-of-pocket spending, including 

9 for stop-loss insurance, and drug utiliza10 tion, including drug adherence; and 

11 (v) patient eligibility criteria for such 

12 programs; and 

13 (B) an analysis of— 

14 (i) the sources of funding for such 

15 programs; and 

16 (ii) the effects of such programs on 

17 Federal health care programs and the indi18 viduals enrolled in such Federal health 

19 care programs. 

20 SEC. 107. REPORTS ON HEALTH CARE TRANSPARENCY 

21 TOOLS AND DATA. 

22 (a) INITIAL REPORT.—Not later than December 31, 

23 2024, the Comptroller General of the United States shall 

24 submit to the Committees (as defined in subsection (d)) 

25 an initial report that— 
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1 (1) identifies and describes health care trans2 parency tools and Federal health care reporting re3 quirements (as described in subsection (d)) that are 

4 in effect as of the date of the submission of such ini5 tial report, including the frequency of reports with 

6 respect to each such requirement and whether any 

7 such requirements are duplicative; 

8 (2) reviews how such reporting requirements 

9 are enforced; 

10 (3) analyzes whether the public availability of 

11 health care transparency tools, and the publication 

12 of data pursuant to such reporting requirements, 

13 has— 

14 (A) been utilized and valued by consumers, 

15 including reasons for such utilization (or lack 

16 thereof); and 

17 (B) assisted health insurance plan spon18 sors and fiduciaries improve benefits, lower 

19 health care costs for plan participants, and 

20 meet fiduciary requirements; 

21 (4) includes recommendations to the Commit22 tees, the Secretary of Health and Human Services, 

23 the Secretary of Labor, and the Secretary of the 

24 Treasury to— 
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1 (A) improve the efficiency, accuracy, and 

2 usability of health care transparency tools; 

3 (B) streamline Federal health care report4 ing requirements to eliminate duplicative re5 quirements and reduce the burden on entities 

6 required to submit reports pursuant to such 

7 provisions; 

8 (C) improve the accuracy and efficiency of 

9 such reports while maintaining the integrity 

10 and usability of the data provided by such re11 ports; 

12 (D) address any gaps in data provided by 

13 such reports; and 

14 (E) ensure that the data and information 

15 reported is comparable and usable to con16 sumers, including patients, plan sponsors, and 

17 policy makers. 

18 (b) FINAL REPORT.—Not later than December 31, 

19 2028, the Comptroller General of the United States shall 

20 submit to the Committees a report that includes— 

21 (1) the information provided in the initial re22 port, along with any updates to such information; 

23 and 

24 (2) any new information with respect to health 

25 care transparency tools that have been released fol-
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1 lowing the submission of such initial report, or new 

2 reporting requirements in effect as of the date of the 

3 submission of the final report. 

4 (c) REPORT ON EXPANDING PRICE TRANSPARENCY

5 REQUIREMENTS.—Not later than December 31, 2025, the 

6 Comptroller General of the United States, in consultation 

7 with the Secretary of Health and Human Services, health 

8 care provider groups, and patient advocacy groups, shall 

9 submit to the Committees a report that includes rec10 ommendations to expand price transparency reporting re11 quirements to additional care settings, with an emphasis 

12 on settings where shoppable services (as defined in sub13 section (d)) are furnished. 

14 (d) DEFINITIONS.—In this section: 

15 (1) COMMITTEES.—The term ‘‘Committees’’ 

16 means the Committee on Ways and Means, the 

17 Committee on Energy and Commerce, and the Com18 mittee on Education and the Workforce of the 

19 House of Representatives, and the Committee on Fi20 nance and the Committee on Health, Education, 

21 Labor, and Pensions of the Senate. 

22 (2) FEDERAL HEALTH CARE REPORTING RE23 QUIREMENTS.—The term ‘‘Federal health care re24 porting requirements’’ includes regulatory and statu25 tory requirements with respect to the reporting and 
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1 publication of health care price, cost access, and 

2 quality data, including requirements established by 

3 the Consolidated Appropriations Act of 2021 (Public 

4 Law 116–260), this Act, and other reporting and 

5 publication requirements with respect to trans6 parency in health care as identified by the Comp7 troller General of the United States. 

8 (3) 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 SEC. 108. REPORT ON INTEGRATION IN MEDICARE. 

14 (a) REQUIRED MA AND PDP REPORTING.— 

15 (1) MA PLANS.—Section 1857(e) of the Social 

16 Security Act (42 U.S.C. 1395w–27(e)) is amended 

17 by adding at the end the following new paragraph: 

18 ‘‘(6) REQUIRED DISCLOSURE OF CERTAIN IN19 FORMATION RELATING TO HEALTH CARE PROVIDER

20 OWNERSHIP.— 

21 ‘‘(A) IN GENERAL.—For plan year 2025 

22 and for every third plan year thereafter, each 

23 applicable MA organization offering an MA 

24 plan under this part during such plan year shall 
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1 submit to the Secretary, at a time and in a 

2 manner specified by the Secretary— 

3 ‘‘(i) the taxpayer identification num4 ber for each health care provider that was 

5 a specified health care provider with re6 spect to such organization during such 

7 year; 

8 ‘‘(ii) the total amount of incentive9 based payments made to, and the total 

10 amount of shared losses recoupments col11 lected from, such specified health care pro12 viders during such plan year; and 

13 ‘‘(iii) the total amount of incentive14 based payments made to, and the total 

15 amount of shared losses recoupments col16 lected from, providers of services and sup17 pliers not described in clause (ii) during 

18 such plan year. 

19 ‘‘(B) DEFINITIONS.—For purposes of this 

20 paragraph: 

21 ‘‘(i) APPLICABLE MA ORGANIZA22 TION.—The term ‘applicable MA organiza23 tion’ means, with respect to a plan year, 

24 an MA organization with at least 25,000 

25 individuals enrolled under Medicare Advan-
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1 tage plans offered by such organization 

2 during such plan year. 

3 ‘‘(ii) SPECIFIED HEALTH CARE PRO4 VIDER.—The term ‘specified health care 

5 provider’ means, with respect to an appli6 cable MA organization and a plan year, a 

7 provider of services or supplier with re8 spect to which such organization (or any 

9 person with an ownership or control inter10 est (as defined in section 1124(a)(3)) in 

11 such organization) is a person with an 

12 ownership or control interest (as so de13 fined).’’. 

14 (2) PRESCRIPTION DRUG PLANS.—Section 

15 1860D–12(b) of the Social Security Act (42 U.S.C. 

16 1395w–112(b)) is amended by adding at the end the 

17 following new paragraph: 

18 ‘‘(9) PROVISION OF INFORMATION RELATING TO

19 PHARMACY OWNERSHIP.— 

20 ‘‘(A) IN GENERAL.—For plan year 2025 

21 and for every third plan year thereafter, each 

22 PDP sponsor offering a prescription drug plan 

23 under this part during such plan year shall sub24 mit to the Secretary, at a time and in a manner 

25 specified by the Secretary, the taxpayer identi-
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1 fication number and National Provider Identi2 fier for each pharmacy that was a specified 

3 pharmacy with respect to such sponsor during 

4 such year. 

5 ‘‘(B) DEFINITION.—For purposes of this 

6 paragraph, the term ‘specified pharmacy’ 

7 means, with respect to an PDP sponsor offering 

8 a prescription drug plan and a plan year, a 

9 pharmacy with respect to which— 

10 ‘‘(i) such sponsor (or any person with 

11 an ownership or control interest (as de12 fined in section 1124(a)(3)) in such spon13 sor) is a person with an ownership or con14 trol interest (as so defined); or 

15 ‘‘(ii) a pharmacy benefit manager of16 fering services under such plan (or any 

17 person with an ownership or control inter18 est (as so defined) in such sponsor) is a 

19 person with an ownership or control inter20 est (as so defined).’’. 

21 (b) MEDPAC REPORTS.—Part E of title XVIII of the 

22 Social Security Act (42 U.S.C. 1395x et seq.), as amended 

23 by section 101, is further amended by adding at the end 

24 the following new section: 
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1 ‘‘SEC. 1899D. REPORTS ON VERTICAL INTEGRATION UNDER 

2 MEDICARE. 

3 ‘‘(a) IN GENERAL.—Not later than June 15, 2029, 

4 and every 3 years thereafter, the Medicare Payment Advi5 sory Commission shall submit to Congress a report on the 

6 state of vertical integration in the health care sector dur7 ing the applicable year with respect to entities partici8 pating in the Medicare program, including health care pro9 viders, pharmacies, prescription drug plan sponsors, Medi10 care Advantage organizations, and pharmacy benefit man11 agers. Such report shall include— 

12 ‘‘(1) with respect to Medicare Advantage orga13 nizations, the evaluation described in subsection (b); 

14 ‘‘(2) with respect to prescription drug plans, 

15 pharmacy benefit managers, and pharmacies, the 

16 comparisons and evaluations described in subsection 

17 (c); 

18 ‘‘(3) with respect to Medicare Advantage plans 

19 under which benefits are available for physician-ad20 ministered drugs, the information described in sub21 section (d); 

22 ‘‘(4) the identifications described in subsection 

23 (e); and 

24 ‘‘(5) an analysis of the impact of such integra25 tion on health care access, price, quality, and out26 comes. 
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1 ‘‘(b) MEDICARE ADVANTAGE ORGANIZATIONS.—For 

2 purposes of subsection (a)(1), the evaluation described in 

3 this subsection is, with respect to Medicare Advantage or4 ganizations and an applicable year, an evaluation, taking 

5 into account patient acuity and the types of areas serviced 

6 by such organization, of— 

7 ‘‘(1) the average number of qualifying diag8 noses made during such year with respect to enroll9 ees of a Medicare Advantage plan offered by such 

10 organization who, during such year, received a 

11 health risk assessment from a specified health care 

12 provider; 

13 ‘‘(2) the average risk score for such enrollees 

14 who received such an assessment during such year; 

15 ‘‘(3) any relationship between such risk scores 

16 for such enrollees receiving such an assessment from 

17 such a provider during such year and incentive pay18 ments made to such providers; 

19 ‘‘(4) the average risk score for enrollees of such 

20 plan who received any item or service from a speci21 fied health care provider during such year; 

22 ‘‘(5) any relationship between the risk scores of 

23 enrollees under such plan and whether the enrollees 

24 have received any item or service from a specified 

25 provider; and 
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1 ‘‘(6) any relationship between the risk scores of 

2 enrollees under such plan that have received any 

3 item or service from a specified provider and incen4 tive payments made under the plan to specified pro5 viders. 

6 ‘‘(c) PRESCRIPTION DRUG PLANS.—For purposes of 

7 subsection (a)(2), the comparisons and evaluations de8 scribed in this subsection are, with respect to prescription 

9 drug plans and an applicable year, the following: 

10 ‘‘(1) For each covered part D drug for which 

11 benefits are available under such a plan, a compari12 son of the average negotiated rate in effect with 

13 specified pharmacies with such rates in effect for in14 network pharmacies that are not specified phar15 macies. 

16 ‘‘(2) Comparisons of the following: 

17 ‘‘(A) The total amount paid by pharmacy 

18 benefit managers to specified pharmacies for 

19 covered part D drugs and the total amount so 

20 paid to pharmacies that are not specified phar21 macies for such drugs. 

22 ‘‘(B) The total amount paid by such spon23 sors to specified pharmacy benefit managers as 

24 reimbursement for covered part D drugs and 

25 the total amount so paid to pharmacy benefit 
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1 managers that are not specified pharmacy ben2 efit managers as such reimbursement. 

3 ‘‘(C) Fees paid under by plan to specified 

4 pharmacy benefit managers compared to such 

5 fees paid to pharmacy benefit managers that 

6 are not specified pharmacy benefit managers. 

7 ‘‘(3) An evaluation of the total amount of direct 

8 and indirect remuneration for covered part D drugs 

9 passed through to prescription drug plan sponsors 

10 and the total amount retained by pharmacy benefit 

11 managers (including entities under contract with 

12 such a manager). 

13 ‘‘(4) To the extent that the available data per14 mits, an evaluation of fees charged by rebate 

15 aggregators that are affiliated with plan sponsors. 

16 ‘‘(d) PHYSICIAN-ADMINISTERED DRUGS.—For pur17 poses of subsection (a)(3), the information described in 

18 this subsection is, with respect to physician-administered 

19 drugs for which benefits are available under a Medicare 

20 Advantage plan during an applicable year, the following: 

21 ‘‘(1) With respect to each such plan, an identi22 fication of each drug for which benefits were avail23 able under such plan only when administered by a 

24 health care provider that acquired such drug from 

25 an affiliated pharmacy. 
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1 ‘‘(2) An evaluation of the difference between 

2 the total number of drugs administered by a health 

3 care provider that were acquired from affiliated 

4 pharmacies compared to the number of such drugs 

5 so administered that were acquired from pharmacies 

6 other than affiliated pharmacies, and an evaluation 

7 of the difference in payments for such drugs so ad8 ministered when acquired from a specified pharmacy 

9 and when acquired from a pharmacy that is not a 

10 specified pharmacy. 

11 ‘‘(3) An evaluation of the dollar value of all 

12 such drugs that were not so administered because of 

13 a delay attributable to an affiliated pharmacy com14 pared to the dollar value of all such drugs that were 

15 not so administered because of a delay attributable 

16 to pharmacy that is not an affiliated pharmacy. 

17 ‘‘(4) The number of enrollees administered such 

18 a drug that was acquired from an affiliated phar19 macy. 

20 ‘‘(5) The number of enrollees furnished such a 

21 drug that was acquired from a pharmacy that is not 

22 an affiliated pharmacy. 

23 ‘‘(e) IDENTIFICATIONS.—For purposes of subsection 

24 (a)(4), the identifications described in this subsection are, 

25 with respect to an applicable year, identifications of each 
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1 health care entity participating under the Medicare pro2 gram with respect to which another health care entity so 

3 participating is a person with an ownership or control in4 terest (as defined in section 1124(a)(3)). 

5 ‘‘(f) DEFINITIONS.—In this section: 

6 ‘‘(1) AFFILIATED PHARMACY.—The term ‘affili7 ated pharmacy’ means, with respect to a Medicare 

8 Advantage plan offered by a Medicare Advantage or9 ganization, a pharmacy with respect to which such 

10 organization (or any person with an ownership or 

11 control interest (as defined in section 1124(a)(3)) in 

12 such organization) is a person with an ownership or 

13 control interest (as so defined). 

14 ‘‘(2) APPLICABLE YEAR.—The term ‘applicable 

15 year’ means, with respect to a report submitted 

16 under subsection (a), the first calendar year begin17 ning at least 4 years prior to the date of the submis18 sion of such report. 

19 ‘‘(3) COVERED PART D DRUG.—The term ‘cov20 ered part D drug’ has the meaning given such term 

21 in section 1860D–2(e). 

22 ‘‘(4) DIRECT AND INDIRECT REMUNERATION.— 

23 The term ‘direct and indirect remuneration’ has the 

24 meaning given such term in section 423.308 of title 
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1 42, Code of Federal Regulations (or any successor 

2 regulation). 

3 ‘‘(5) QUALIFYING DIAGNOSIS.—The term ‘quali4 fying diagnosis’ means, with respect to an enrollee of 

5 a Medicare Advantage plan, a diagnosis that is 

6 taken into account in calculating a risk score for 

7 such enrollee under the risk adjustment methodology 

8 established by the Secretary pursuant to section 

9 1853(a)(3). 

10 ‘‘(6) RISK SCORE.—The term ‘risk score’ 

11 means, with respect to an enrollee of a Medicare Ad12 vantage plan, the score calculated for such individual 

13 using the methodology described in paragraph (5). 

14 ‘‘(7) PHYSICIAN-ADMINISTERED DRUG.—The 

15 term ‘physician-administered drug’ means a drug 

16 furnished to an individual that, had such individual 

17 been enrolled under part B and not enrolled under 

18 part C, would have been payable under section 

19 1842(o). 

20 ‘‘(8) SPECIFIED HEALTH CARE PROVIDER.— 

21 The term ‘specified health care provider’ means, 

22 with respect to a Medicare Advantage plan offered 

23 by a Medicare Advantage organization, a health care 

24 provider with respect to which such organization (or 

25 any person with an ownership or control interest (as 
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1 defined in section 1124(a)(3)) in such organization) 

2 is a person with an ownership or control interest (as 

3 so defined). 

4 ‘‘(9) SPECIFIED PHARMACY.—The term ‘speci5 fied pharmacy’ means, with respect to a prescription 

6 drug plan offered by a prescription drug plan spon7 sor, a pharmacy with respect to which— 

8 ‘‘(A) such sponsor (or any person with an 

9 ownership or control interest (as defined in sec10 tion 1124(a)(3)) in such sponsor) is a person 

11 with an ownership or control interest (as so de12 fined); or 

13 ‘‘(B) a pharmacy benefit manager offering 

14 services under such plan (or any person with an 

15 ownership or control interest (as so defined) in 

16 such sponsor) is a person with an ownership or 

17 control interest (as so defined). 

18 ‘‘(10) SPECIFIED PHARMACY BENEFIT MAN19 AGER.—The term ‘specified pharmacy benefit man20 ager’ means, with respect to a prescription drug 

21 plan offered by a prescription drug plan sponsor, a 

22 pharmacy benefit manager with respect to which 

23 such sponsor (or any person with an ownership or 

24 control interest (as defined in section 1124(a)(3)) in 
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1 such sponsor) is a person with an ownership or con2 trol interest (as so defined).’’. 

3 SEC. 109. ADVISORY COMMITTEE. 

4 (a) IN GENERAL.—Not later than January 1, 2025, 

5 the Secretary of Labor, the Secretary of Health and 

6 Human Services, and the Secretary of the Treasury shall 

7 jointly convene an advisory committee (in this section re8 ferred to as the ‘‘committee’’) consisting of 9 members to 

9 advise the Secretaries on how to improve the usefulness, 

10 accessibility, and usability of information made available 

11 in accordance the amendments made by sections 105 and 

12 106, and by section 204 of division BB of the Consolidated 

13 Appropriation Act, 2021 (Public Law 116–260), stream14 line the reporting of such information, and ensure that— 

15 (1) such information is accurate, accessible, and 

16 is delivered in a form and manner consistent with 

17 the requirements of such section; 

18 (2) the form and manner in which such infor19 mation is delivered is routinely updated in accord20 ance with widely-used practices in order to ensure 

21 accessibility; and 

22 (3) such information is available for audit (in23 cluding by making recommendations relating to how 

24 Federal and State actors may conduct such audits). 
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1 (b) MEMBERSHIP.—The Secretaries shall jointly ap2 point members representing end-users of the information 

3 described in subsection (a). Vacancies on the committee 

4 shall be filled by appointment consistent with this sub5 section not later than 3 months after the vacancy arises. 

6 (c) TERMINATION.—The committee shall terminate 

7 on January 1, 2028. 

8 (d) NONAPPLICAITON OF FACA.—The Federal Advi9 sory Committee Act (5 U.S.C. App.) shall not apply to 

10 the committee. 

11 SEC. 110. REPORT ON IMPACT OF MEDICARE REGULATIONS 

12 ON PROVIDER AND PAYER CONSOLIDATION. 

13 (a) ANNUAL REPORT ON THE IMPACT OF CERTAIN

14 MEDICARE REGULATIONS ON PROVIDER AND PAYER

15 CONSOLIDATION; PUBLIC COMMENT ON PROVIDER AND

16 PAYER CONSOLIDATION FOR CERTAIN PROPOSED

17 RULES.— 

18 (1) ANNUAL REPORT.—Not later than Decem19 ber 30, 2026, and annually thereafter, the Secretary 

20 of Health and Human Services (in this section re21 ferred to as the ‘‘Secretary’’) shall submit to Con22 gress a report on the impact in the aggregate on 

23 provider and payer consolidation with respect to reg24 ulations for parts A, B, C, and D of title XVIII of 

25 the Social Security Act (42 U.S.C. 1395 et seq.) im-
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1 plemented in the calendar year immediately prior to 

2 such report. Such report shall include regulations 

3 that— 

4 (A) implement a change to an applicable 

5 payment system, a rate schedule, or another 

6 payment system under part A, B, C, or D of 

7 such title; or 

8 (B) result in a significant rule effecting 

9 provider or payer consolidation. 

10 (2) PUBLIC COMMENT ON IMPACT TO PROVIDER

11 AND PAYER CONSOLIDATION.—Beginning for 2025, 

12 as part of any notice and comment rulemaking proc13 ess that will result in a significant rule effecting pro14 vider or payer consolidation with respect to a pro15 posed rule for parts A, B, C, and D of title XVIII 

16 of the Social Security Act (42 U.S.C. 1395j et seq.), 

17 the Secretary shall seek public comment on the pro18 jected impact of such proposed rule on provider and 

19 payer consolidation in the aggregate. 

20 (3) DEFINITIONS.—In this section: 

21 (A) PROVIDER AND PAYER CONSOLIDA22 TION.—The term ‘‘provider and payer consoli23 dation’’ includes the vertical or horizontal inte24 gration among providers of services (as defined 

25 in subsection (u) of section 1861 of the Social 
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1 Security Act (42 U.S.C. 1395x)), suppliers (as 

2 defined in subsection (d) of such section), ac3 countable care organizations under section 1899 

4 of the Social Security Act (42 U.S.C. 1395jjj), 

5 Medicare Advantage organizations, PDP spon6 sors, pharmacy benefit managers, pharmacies, 

7 and integrated delivery systems. 

8 (B) APPLICABLE PAYMENT SYSTEM.—The 

9 term ‘‘applicable payment system’’ includes— 

10 (i) with respect to outpatient hospital 

11 services, the prospective payment system 

12 for covered OPD services established under 

13 section 1833(t) of such Act (42 U.S.C. 

14 1395(l)); and 

15 (ii) with respect to physicians’ serv16 ices, the physician fee schedules established 

17 under section 1848 of such Act (42 U.S.C. 

18 1395w–4). 

19 (b) CONSIDERATION OF EFFECTS ON PROVIDER AND

20 PAYER CONSOLIDATION WITH RESPECT TO CMI MOD21 ELS.— 

22 (1) IN GENERAL.—Section 1115A(b)(4)(A) of 

23 the Social Security Act (42 U.S.C. 1315a(b)(4)(A)) 

24 is amended— 
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1 (A) in clause (i), by striking at the end 

2 ‘‘and’’; 

3 (B) in clause (ii), by striking the period at 

4 the end and inserting ‘‘; and’’; and 

5 (C) by adding at the end the following new 

6 clause: 

7 ‘‘(iii) the extent to which, and how, 

8 the model has effected and could effect 

9 provider and payer consolidation, which in10 cludes the vertical or horizontal integration 

11 among providers of services (as defined in 

12 subsection (u) of section 1861), suppliers 

13 (as defined in subsection (d) of such sec14 tion), and accountable care organizations 

15 under section 1899.’’. 

16 (2) EFFECTIVE DATE.—The amendments made 

17 by paragraph (1) shall apply with respect to models 

18 tested on or after January 1, 2025. 

19 SEC. 111. IMPLEMENTATION FUNDING. 

20 (a) IN GENERAL.—For the purposes described in 

21 subsection (b), there are appropriated, in addition to 

22 amounts otherwise available, out of amounts in the Treas23 ury not otherwise appropriated, to the Secretary of Health 

24 and Human Services and the Secretary of the Treasury, 
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1 $65,000,000 for fiscal year 2024, to remain available 

2 through fiscal year 2029. 

3 (b) PERMITTED PURPOSES.—The purposes described 

4 in this subsection are the following purposes, insofar as 

5 such purposes are to carry out the provisions of, including 

6 the amendments made by, this title: 

7 (1) Preparing, drafting, and issuing proposed 

8 and final regulations or interim regulations. 

9 (2) Preparing, drafting, and issuing guidance 

10 and public information. 

11 (3) Preparing, drafting, and publishing reports. 

12 (4) Enforcement of such provisions. 

13 (5) Reporting, collection, and analysis of data. 

14 (6) Other administrative duties necessary for 

15 implementation of such provisions. 

16 (c) TRANSPARENCY OF IMPLEMENTATION FUNDS.— 

17 Each Secretary described in subsection (a) shall annually 

18 submit, no later than September 1st of each year, to the 

19 Committees on Energy and Commerce, on Ways and 

20 Means, on Education and Workforce, and on Appropria21 tions of the House of Representatives and on the Commit22 tees on Health, Education, Labor, and Pensions and on 

23 Appropriations of the Senate a report on funds expended 

24 pursuant to funds appropriated under this section. 
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1 TITLE II—REDUCING HEALTH 

2 CARE COSTS FOR PATIENTS 

3 SEC. 201. INCREASING TRANSPARENCY IN GENERIC DRUG 

4 APPLICATIONS. 

5 (a) IN GENERAL.—Section 505(j)(3) of the Federal 

6 Food, Drug, and Cosmetic Act (21 U.S.C. 355(j)(3)) is 

7 amended by adding at the end the following: 

8 ‘‘(H)(i) Upon request (in controlled correspondence 

9 or an analogous process) by a person that has submitted 

10 or intends to submit an abbreviated application under this 

11 subsection for a drug that is required by regulation to con12 tain one or more of the same inactive ingredients in the 

13 same concentrations as the listed drug referred to, or for 

14 which the Secretary determines there is a scientific jus15 tification for an approach that is in vitro in whole or in 

16 part to be used to demonstrate bioequivalence for a drug 

17 if such a drug contains one or more of the same inactive 

18 ingredients in the same concentrations as the listed drug, 

19 the Secretary shall inform the person whether such drug 

20 is qualitatively and quantitatively the same as the listed 

21 drug. The Secretary may also provide such information 

22 to such a person on the Secretary’s own initiative during 

23 the review of an abbreviated application under this sub24 section for such drug. 
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1 ‘‘(ii) Notwithstanding section 301(j), if the Secretary 

2 determines that such drug is not qualitatively or quan3 titatively the same as the listed drug, the Secretary shall 

4 identify and disclose to the person— 

5 ‘‘(I) the ingredient or ingredients that cause 

6 such drug not to be qualitatively or quantitatively 

7 the same as the listed drug; and 

8 ‘‘(II) for any ingredient for which there is an 

9 identified quantitative deviation, the amount of such 

10 deviation. 

11 ‘‘(iii) If the Secretary determines that such drug is 

12 qualitatively and quantitatively the same as the listed 

13 drug, the Secretary shall not change or rescind such deter14 mination after the submission of an abbreviated applica15 tion for such drug under this subsection unless— 

16 ‘‘(I) the formulation of the listed drug has been 

17 changed and the Secretary has determined that the 

18 prior listed drug formulation was withdrawn for rea19 sons of safety or effectiveness; or 

20 ‘‘(II) the Secretary makes a written determina21 tion that the prior determination must be changed 

22 because an error has been identified. 

23 ‘‘(iv) If the Secretary makes a written determination 

24 described in clause (iii)(II), the Secretary shall provide no-
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1 tice and a copy of the written determination to the person 

2 making the request under clause (i). 

3 ‘‘(v) The disclosures required by this subparagraph 

4 are disclosures authorized by law, including for purposes 

5 of section 1905 of title 18, United States Code.’’. 

6 (b) GUIDANCE.— 

7 (1) IN GENERAL.—Not later than one year 

8 after the date of enactment of this Act, the Sec9 retary of Health and Human Services shall issue 

10 draft guidance, or update guidance, describing how 

11 the Secretary will determine whether a drug is quali12 tatively and quantitatively the same as the listed 

13 drug (as such terms are used in section 

14 505(j)(3)(H) of the Federal Food, Drug, and Cos15 metic Act, as added by subsection (a)), including 

16 with respect to assessing pH adjusters. 

17 (2) PROCESS.—In issuing guidance under this 

18 subsection, the Secretary of Health and Human 

19 Services shall— 

20 (A) publish draft guidance; 

21 (B) provide a period of at least 60 days for 

22 comment on the draft guidance; and 

23 (C) after considering any comments re24 ceived and not later than one year after the 
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1 close of the comment period on the draft guid2 ance, publish final guidance. 

3 (c) APPLICABILITY.—Section 505(j)(3)(H) of the 

4 Federal Food, Drug, and Cosmetic Act, as added by sub5 section (a), applies beginning on the date of enactment 

6 of this Act, irrespective of the date on which the guidance 

7 required by subsection (b) is finalized. 

8 SEC. 202. IMPROVING TRANSPARENCY AND PREVENTING 

9 THE USE OF ABUSIVE SPREAD PRICING AND 

10 RELATED PRACTICES IN MEDICAID. 

11 (a) SPREAD PRICING.— 

12 (1) IN GENERAL.—Section 1927(e) of the So13 cial Security Act (42 U.S.C. 1396r–8(e)) is amended 

14 by adding at the end the following: 

15 ‘‘(6) PHARMACY PRICE REIMBURSEMENT RE16 QUIRED.— 

17 ‘‘(A) IN GENERAL.—A contract between 

18 the State and a pharmacy benefit manager (in 

19 this paragraph referred to as a ‘PBM’), or a 

20 contract between the State and a designated en21 tity (as defined in subparagraph (C)) that in22 cludes provisions making the designated entity 

23 responsible for the administration of medical 

24 assistance consisting of covered outpatient 

25 drugs for individuals enrolled with the des-
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1 ignated entity, shall require that payment for 

2 such drugs and related administrative services 

3 (as applicable), including payments made by a 

4 PBM on behalf of the State or designated enti5 ty, is based on a pharmacy price reimbursement 

6 model under which— 

7 ‘‘(i) any payment made by the des8 ignated entity or the PBM (as applicable) 

9 for such a drug— 

10 ‘‘(I) is limited to— 

11 ‘‘(aa) ingredient cost; and 

12 ‘‘(bb) a professional dis13 pensing fee that is not less than 

14 the professional dispensing fee 

15 that the State plan or waiver 

16 would pay if the plan or waiver 

17 was making the payment directly; 

18 ‘‘(II) is passed through in its en19 tirety by the designated entity or 

20 PBM to the pharmacy or provider 

21 that dispenses the drug and is not 

22 retroactively denied or reduced except 

23 as permitted or required under Fed24 eral or State law or regulation; and 
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1 ‘‘(III) is made in a manner that 

2 is consistent with sections 447.502, 

3 447.512, 447.514, and 447.518 of 

4 title 42, Code of Federal Regulations 

5 (or any successor regulation) as if 

6 such requirements applied directly to 

7 the designated entity or the PBM, ex8 cept that any payment by the des9 ignated entity or the PBM for the in10 gredient cost of such a drug pur11 chased by a covered entity (as defined 

12 in subsection (a)(5)(B)) may exceed 

13 the actual acquisition cost (as defined 

14 in section 447.502 of title 42, Code of 

15 Federal Regulations (or any successor 

16 regulation)) for such drug if— 

17 ‘‘(aa) such drug was subject 

18 to an agreement under section 

19 340B of the Public Health Serv20 ice Act; 

21 ‘‘(bb) such payment for such 

22 cost of such drug does not exceed 

23 the maximum payment that 

24 would have been made by the 

25 designated entity or the PBM for 
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1 the ingredient cost of such drug 

2 had such drug not been pur3 chased by such a covered entity; 

4 and 

5 ‘‘(cc) such covered entity re6 ports to the Secretary, on an an7 nual basis (in a form and manner 

8 specified by the Secretary) and 

9 with respect to payments for 

10 such costs of such drugs so pur11 chased by such covered entity 

12 that are in excess of the actual 

13 acquisition costs for such drugs, 

14 the aggregate amount of such ex15 cess; 

16 ‘‘(ii) payment to the designated entity 

17 or the PBM (as applicable) for administra18 tive services performed by the designated 

19 entity or PBM is limited to an administra20 tive fee that reflects the fair market value 

21 of providing such services; 

22 ‘‘(iii) the designated entity or the 

23 PBM (as applicable) makes available to 

24 the State, and the Secretary upon request, 

25 all costs and payments related to covered 
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1 outpatient drugs and accompanying admin2 istrative services incurred, received, or 

3 made by the designated entity or the PBM, 

4 including ingredient costs, professional dis5 pensing fees, administrative fees, post-sale 

6 and post-invoice fees, discounts, or related 

7 adjustments such as direct and indirect re8 muneration fees, and any and all other re9 muneration; and 

10 ‘‘(iv) any form of spread pricing 

11 whereby any amount charged or claimed by 

12 the designated entity or the PBM (as ap13 plicable) is in excess of the amount paid to 

14 the pharmacies by the designated entity or 

15 the PBM, including any post-sale or post16 invoice fees, discounts, or related adjust17 ments such as direct and indirect remu18 neration fees or assessments (after allow19 ing for a fair market administrative fee as 

20 described in clause (ii)), is not allowable 

21 for purposes of claiming Federal matching 

22 payments under this title. 

23 ‘‘(B) MAKING CERTAIN INFORMATION

24 AVAILABLE.—The Secretary shall publish, not 

25 less frequently than on an annual basis, infor-
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1 mation received by the Secretary pursuant to 

2 subparagraph (A)(i)(III)(cc). Such information 

3 shall be so published in an electronic and 

4 searchable format, such as through the 340B 

5 Office of Pharmacy Affairs Information System 

6 (or a successor system). 

7 ‘‘(C) DEFINITIONS.—In this paragraph: 

8 ‘‘(i) DESIGNATED ENTITY.—The term 

9 ‘designated entity’ means a managed care 

10 entity or other specified entity. 

11 ‘‘(ii) MANAGED CARE ENTITY; OTHER

12 SPECIFIED ENTITY.—The terms ‘managed 

13 care entity’ and ‘other specified entity’ 

14 have the meaning given such terms in sec15 tion 1903(m)(9)(D).’’. 

16 (2) CONFORMING AMENDMENTS.—Section 

17 1903(m) of such Act (42 U.S.C. 1396b(m)) is 

18 amended— 

19 (A) in paragraph (2)(A)(xiii)— 

20 (i) by striking ‘‘and (III)’’ and insert21 ing ‘‘(III)’’; 

22 (ii) by inserting before the period at 

23 the end the following: ‘‘, and (IV) with re24 spect to covered outpatient drugs and re25 lated administrative services (as applicable) 
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1 provided by the entity (or by a pharmacy 

2 benefit manager on behalf of the entity 

3 under a contract or other arrangement 

4 with the entity), that payment for such 

5 drugs and related administrative services is 

6 based on a pharmacy price reimbursement 

7 model described in section 1927(e)(6)(A)’’; 

8 and 

9 (iii) by moving the margin 2 ems to 

10 the left; and 

11 (B) by adding at the end the following new 

12 paragraph: 

13 ‘‘(10) No payment shall be made under this title to 

14 a State with respect to expenditures incurred by it for pay15 ment for services provided by an other specified entity (as 

16 defined in paragraph (9)(D)) unless the contract between 

17 the State and the entity for the provision of such services 

18 provides, with respect to covered outpatient drugs and re19 lated administrative services (as applicable) provided by 

20 the entity (or by a pharmacy benefit manager on behalf 

21 of the entity under a contract or other arrangement with 

22 the entity), that payment for such drugs and related ad23 ministrative services is based on a pharmacy price reim24 bursement model described in section 1927(e)(6)(A).’’. 
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1 (3) EFFECTIVE DATE.—The amendments made 

2 by this subsection apply to contracts between States 

3 and pharmacy benefit managers and designated enti4 ties (as defined in section 1927(e)(6) of the Social 

5 Security Act, as added by paragraph (1)) that have 

6 an effective date beginning on or after the date that 

7 is 18 months after the date of enactment of this Act. 

8 (b) ENSURING ACCURATE PAYMENTS TO PHAR9 MACIES UNDER MEDICAID.— 

10 (1) IN GENERAL.—Section 1927(f) of the Social 

11 Security Act (42 U.S.C. 1396r–8(f)) is amended— 

12 (A) by striking ‘‘and’’ after the semicolon 

13 at the end of paragraph (1)(A)(i) and all that 

14 precedes it through ‘‘(1)’’ and inserting the fol15 lowing: 

16 ‘‘(1) DETERMINING PHARMACY ACTUAL ACQUI17 SITION COSTS.—The Secretary shall conduct a sur18 vey of retail community pharmacy drug prices to de19 termine the national average drug acquisition cost as 

20 follows: 

21 ‘‘(A) USE OF VENDOR.—The Secretary 

22 may contract services for— 

23 ‘‘(i) with respect to retail community 

24 pharmacies, the determination of retail 

25 survey prices of the national average drug 
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1 acquisition cost for covered outpatient 

2 drugs based on a monthly survey of such 

3 pharmacies; and’’; 

4 (B) by adding at the end of paragraph (1) 

5 the following: 

6 ‘‘(F) SURVEY REPORTING.—A State shall 

7 require that any retail community pharmacy in 

8 the State that receives any payment, reimburse9 ment, administrative fee, discount, or rebate re10 lated to the dispensing of covered outpatient 

11 drugs to individuals receiving benefits under 

12 this title, regardless of whether such payment, 

13 reimbursement, administrative fee, discount, or 

14 rebate is received from the State or a des15 ignated entity (as defined in subsection 

16 (e)(6)(C)) directly or from a pharmacy benefit 

17 manager that has a contract with the State or 

18 a designated entity, shall respond to surveys of 

19 retail prices conducted under this subsection. 

20 ‘‘(G) SURVEY INFORMATION.—Information 

21 on national drug acquisition prices obtained 

22 under this paragraph shall be made publicly 

23 available in a timely manner following the col24 lection of such information and shall include at 

25 least the following: 
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1 ‘‘(i) The monthly response rate to the 

2 survey including a list of pharmacies not in 

3 compliance with subparagraph (F). 

4 ‘‘(ii) The sampling frame and number 

5 of pharmacies sampled monthly. 

6 ‘‘(iii) Information on price concessions 

7 to the pharmacy, including discounts, re8 bates, and other price concessions, to the 

9 extent that such information may be pub10 licly released and is available during the 

11 survey period. 

12 ‘‘(H) REPORT ON SPECIALTY PHAR13 MACIES.—Not later than 1 year after the date 

14 that this subparagraph takes effect, the Sec15 retary shall submit to Congress a report exam16 ining specialty drug coverage and reimburse17 ment under this title, including— 

18 ‘‘(i) a description of how State Med19 icaid programs define specialty drugs and 

20 specialty pharmacies; 

21 ‘‘(ii) the amount State Medicaid pro22 grams pay for specialty drugs; 

23 ‘‘(iii) how States and designated enti24 ties (as defined in subsection (e)(6)(C)) de25 termine payment for specialty drugs; 
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1 ‘‘(iv) the settings in which specialty 

2 drugs are dispensed to individuals receiv3 ing benefits under this title (such as retail 

4 community pharmacies or specialty phar5 macies); 

6 ‘‘(v) the extent to which specialty 

7 drugs (as defined by the respective States) 

8 are captured in the national average drug 

9 acquisition cost survey (or through another 

10 process); 

11 ‘‘(vi) examples of specialty drug dis12 pensing fees to support the services associ13 ated with dispensing such specialty drugs; 

14 and 

15 ‘‘(vii) recommendations as to whether 

16 specialty pharmacies should be included in 

17 the survey of retail prices to ensure na18 tional average drug acquisition costs cap19 ture drugs sold at specialty pharmacies, 

20 and how such specialty pharmacies should 

21 be defined. 

22 ‘‘(I) ENFORCEMENT.—At the discretion of 

23 the Secretary, the Secretary (acting through the 

24 Inspector General and in collaboration with the 

25 Administrator of the Centers for Medicare & 
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1 Medicaid Services) may enforce non-compliance 

2 with this paragraph by a pharmacy through the 

3 establishment of penalties until compliance with 

4 this paragraph has been completed.’’; and 

5 (C) in paragraph (2)— 

6 (i) in subparagraph (A), by inserting 

7 ‘‘(including payment rates under managed 

8 care organization as defined in section 

9 1932(a)(1)(B)(i) and PIHPs and PAHPs 

10 as defined in section 1903(m)(9)(D)(iii)(I) 

11 and (II), respectively)’’ after ‘‘under this 

12 title’’; and 

13 (ii) in subparagraph (B), by inserting 

14 ‘‘, and the basis for such dispensing fees’’ 

15 before the semicolon at the end. 

16 (2) EFFECTIVE DATE.—The amendments made 

17 by this subsection shall take effect on the first day 

18 of the first quarter that begins on or after the date 

19 that is 18 months after the date of enactment of 

20 this Act. 
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1 SEC. 203. PARITY IN MEDICARE PAYMENTS FOR HOSPITAL 

2 OUTPATIENT DEPARTMENT SERVICES FUR3 NISHED OFF-CAMPUS. 

4 (a) IN GENERAL.—Section 1833(t)(16) of the Social 

5 Security Act (42 U.S.C. 1395l(t)(16)) is amended by add6 ing at the end the following new subparagraph: 

7 ‘‘(H) PARITY IN FEE SCHEDULE AMOUNT

8 FOR CERTAIN SERVICES FURNISHED BY AN

9 OFF-CAMPUS OUTPATIENT DEPARTMENT OF A

10 PROVIDER.— 

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

12 (iii), in the case of specified OPD services 

13 (as defined in clause (v)) that are fur14 nished during 2025 or a subsequent year 

15 by an off-campus outpatient department of 

16 a provider (as defined in clause (iv)) (or, 

17 in the case of an off-campus outpatient de18 partment of a provider that is a hospital 

19 described in section 1886(d)(1)(B)(v), or is 

20 located in a rural area or a health profes21 sional shortage area, such services that are 

22 furnished during 2026 or a subsequent 

23 year), there shall be substituted for the 

24 amount otherwise determined under this 

25 subsection for such service and year an 

26 amount equal to the payment amount that 
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1 would have been payable under the applica2 ble payment system under this part (other 

3 than under this subsection) had such serv4 ices been furnished by such a department 

5 subject to such payment system pursuant 

6 to paragraph (21)(C). 

7 ‘‘(ii) NOT BUDGET NEUTRAL IMPLE8 MENTATION.—In making any budget neu9 trality adjustments under this subsection 

10 for 2025 or a subsequent year, the Sec11 retary shall not take into account the re12 duced expenditures that result from the 

13 application of this subparagraph. 

14 ‘‘(iii) TRANSITION.—The Secretary 

15 shall provide for a 4-year phase-in of the 

16 application of clause (i), with clause (i) 

17 being fully applicable for specified OPD 

18 services beginning with 2028 (or in the 

19 case of an off-campus outpatient depart20 ment of a provider that is a hospital de21 scribed in section 1886(d)(1)(B)(v), or is 

22 located in a rural area or a health profes23 sional shortage area, beginning with 2029). 

24 ‘‘(iv) OFF-CAMPUS DEPARTMENT OF A

25 PROVIDER.—For purposes of this subpara-
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1 graph, the term ‘off-campus outpatient de2 partment of a provider’ means a depart3 ment of a provider (as defined in section 

4 413.65(a)(2) of title 42, Code of Federal 

5 Regulations) that is not located— 

6 ‘‘(I) on the campus (as such term 

7 is defined in such section) of such 

8 provider; or 

9 ‘‘(II) within the distance (de10 scribed in such definition of campus) 

11 from a remote location of a hospital 

12 facility (as defined in such section). 

13 ‘‘(v) OTHER DEFINITIONS.—For pur14 poses of this subparagraph: 

15 ‘‘(I) DESIGNATED AMBULATORY

16 PAYMENT CLASSIFICATION GROUP.— 

17 The term ‘designated ambulatory pay18 ment classification group’ means an 

19 ambulatory payment classification 

20 group for drug administration serv21 ices. 

22 ‘‘(II) HEALTH PROFESSIONAL

23 SHORTAGE AREA.—The term ‘health 

24 professional shortage area’ has the 

25 meaning given such term in section 
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1 332(a)(1)(A) of the Public Health 

2 Service Act. 

3 ‘‘(III) RURAL AREA.—The term 

4 ‘rural area’ has the meaning given 

5 such term in section 1886(d)(2)(D). 

6 ‘‘(IV) SPECIFIED OPD SERV7 ICES.—The term ‘specified OPD serv8 ices’ means covered OPD services as9 signed to a designated ambulatory 

10 payment classification group.’’. 

11 (b) IMPLEMENTATION.—Section 1833(t)(12) of the 

12 Social Security Act (42 U.S.C. 1395l(t)(12)) is amend13 ed— 

14 (1) in subparagraph (D), by striking ‘‘and’’ at 

15 the end; 

16 (2) in subparagraph (E), by striking the period 

17 at the end and inserting ‘‘; and’’; and 

18 (3) by adding at the end the following new sub19 paragraph: 

20 ‘‘(F) the determination of any payment 

21 amount under paragraph (16)(H), including the 

22 transition under clause (iii) of such para23 graph.’’. 
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1 SEC. 204. REQUIRING A SEPARATE IDENTIFICATION NUM2 BER AND AN ATTESTATION FOR EACH OFF3 CAMPUS OUTPATIENT DEPARTMENT OF A 

4 PROVIDER. 

5 (a) IN GENERAL.—Section 1833(t) of the Social Se6 curity Act (42 U.S.C. 1395l(t)) is amended by adding at 

7 the end the following new paragraph: 

8 ‘‘(23) USE OF UNIQUE HEALTH IDENTIFIERS; 

9 ATTESTATION.— 

10 ‘‘(A) IN GENERAL.—No payment may be 

11 made under this subsection (or under an appli12 cable payment system pursuant to paragraph 

13 (21)) for items and services furnished on or 

14 after January 1, 2026, by an off-campus out15 patient department of a provider (as defined in 

16 subparagraph (C)) unless— 

17 ‘‘(i) such department has obtained, 

18 and such items and services are billed 

19 under, a standard unique health identifier 

20 for health care providers (as described in 

21 section 1173(b)) that is separate from 

22 such identifier for such provider; and 

23 ‘‘(ii) such provider has submitted to 

24 the Secretary, during the 2-year period 

25 ending on the date such items and services 

26 are so furnished, an attestation that such 
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1 department is compliant with the require2 ments described in section 413.65 of title 

3 42, Code of Federal Regulations (or a suc4 cessor regulation). 

5 ‘‘(B) PROCESS FOR SUBMISSION AND RE6 VIEW.—Not later than 1 year after the date of 

7 enactment of this paragraph, the Secretary 

8 shall, through notice and comment rulemaking, 

9 establish a process for each provider with an 

10 off-campus outpatient department of a provider 

11 to submit an attestation pursuant to subpara12 graph (A)(ii), and for the Secretary to review 

13 each such attestation and determine, through 

14 site visits, remote audits, or other means (as 

15 determined appropriate by the Secretary), 

16 whether such department is compliant with the 

17 requirements described in such subparagraph. 

18 ‘‘(C) OFF-CAMPUS OUTPATIENT DEPART19 MENT OF A PROVIDER DEFINED.—For purposes 

20 of this paragraph, the term ‘off-campus out21 patient department of a provider’ means a de22 partment of a provider (as defined in section 

23 413.65 of title 42, Code of Federal Regulations, 

24 or any successor regulation) that is not lo25 cated— 
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1 ‘‘(i) on the campus (as defined in such 

2 section) of such provider; or 

3 ‘‘(ii) within the distance (described in 

4 such definition of campus) from a remote 

5 location of a hospital facility (as defined in 

6 such section).’’. 

7 (b) HHS OIG ANALYSIS.—Not later than January 

8 1, 2030, the Inspector General of the Department of 

9 Health and Human Services shall submit to Congress— 

10 (1) an analysis of the process established by the 

11 Secretary of Health and Human Services to conduct 

12 the reviews and determinations described in section 

13 1833(t)(23)(B) of the Social Security Act, as added 

14 by subsection (a) of this section; and 

15 (2) recommendations based on such analysis, as 

16 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) $16,635,616 for the period beginning 

16 on October 1, 2023, and ending on November 

17 17, 2023; 

18 ‘‘(E) $21,834,247 for the period beginning 

19 on November 18, 2023, and ending on January 

20 19, 2024; 

21 ‘‘(F) $136,530,137 for the period begin22 ning on January 20, 2024, and ending on Sep23 tember 30, 2024; 

24 ‘‘(G) $175,000,000 for fiscal year 2025; 
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1 ‘‘(H) $225,000,000 for each of fiscal years 

2 2026 and 2027; and 

3 ‘‘(I) $300,000,000 for each of fiscal years 

4 2028, 2029, and 2030.’’; and 

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

6 ‘‘(3) AVAILABILITY.—The amounts made avail7 able under paragraph (1) shall remain available until 

8 expended.’’. 

9 (b) EXTENSION FOR COMMUNITY HEALTH CEN10 TERS.—Section 10503(b)(1)(F) of the Patient Protection 

11 and Affordable Care Act (42 U.S.C. 254b–2(b)(1)(F)) is 

12 amended— 

13 (1) by striking ‘‘and’’ before ‘‘$690,410,959’’; 

14 and 

15 (2) by inserting ‘‘, $3,183,561,644 for the pe16 riod beginning on January 20, 2024, and ending on 

17 September 30, 2024, $4,400,000,000 for fiscal year 

18 2025, and $1,109,000,000 for the period beginning 

19 October 1, 2025, and ending December 31, 2025’’ 

20 before the semicolon at the end. 

21 (c) EXTENSION FOR THE NATIONAL HEALTH SERV22 ICE CORPS.—Section 10503(b)(2) of the Patient Protec23 tion and Affordable Care Act (42 U.S.C. 254b–2(b)(2)) 

24 is amended— 
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1 (1) in subparagraph (H), by striking ‘‘and’’ at 

2 the end; 

3 (2) in subparagraph (I), by striking the period 

4 at the end and inserting ‘‘; and’’; and 

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

6 ‘‘(J) $255,726,028 for the period begin7 ning on January 20, 2024, and ending on Sep8 tember 30, 2024, $350,000,000 for fiscal year 

9 2025, and $88,219,178 for the period beginning 

10 October 1, 2025, and ending December 31, 

11 2025.’’. 

12 (d) GOVERNMENT ACCOUNTABILITY OFFICE RE13 PORT.— 

14 (1) IN GENERAL.—Not later than one year 

15 after the date of enactment of this Act, the Comp16 troller General of the United States shall submit to 

17 the Committee on Energy and Commerce of the 

18 House of Representatives and the Committee on 

19 Health, Education, Labor, and Pensions of the Sen20 ate a report assessing the effectiveness of the Na21 tional Health Service Corps at attracting health care 

22 professionals to HPSAs, including by— 

23 (A) assessing the metrics used by the 

24 Health Resources and Services Administration 

25 in evaluating the program; 
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1 (B) comparing the retention rates of 

2 NHSC participants in the HPSAs where they 

3 completed their period of obligated service to 

4 the retention rate of non-NHSC participants in 

5 the corresponding HPSAs; 

6 (C) comparing the retention rates of 

7 NHSC participants in the HPSAs where they 

8 completed their period of obligated service to 

9 the retention rates of NHSC participants in 

10 HPSAs other than those where they completed 

11 their period of obligated service; 

12 (D) identifying factors that influence a 

13 NHSC participant’s decision to practice in a 

14 HPSA other than the HPSA where they com15 pleted their period of obligated service; 

16 (E) identifying factors other than partici17 pation in the National Health Service Corps 

18 Scholarship and Loan Repayment Programs 

19 that attract health care professionals to a 

20 HPSA; 

21 (F) assessing the impact the National 

22 Health Service Corps has on wages for health 

23 care professionals in a HPSA; and 
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1 (G) comparing the distribution of NHSC 

2 participants across HPSAs, including a com3 parison of rural versus non-rural HPSAs. 

4 (2) DEFINITION.—In this section: 

5 (A) The term ‘‘HPSA’’ means a health 

6 professional shortage area designated under 

7 section 332 of the Public Health Service Act 

8 (42 U.S.C. 254e). 

9 (B) The term ‘‘NHSC participant’’ means 

10 a National Health Service Corps member par11 ticipating in the National Health Service Corps 

12 Scholarship or Loan Repayment Program. 

13 (e) APPLICATION OF PROVISIONS.—Amounts appro14 priated pursuant to the amendments made by this section 

15 shall be subject to the requirements contained in Public 

16 Law 117–328 for funds for programs authorized under 

17 sections 330 through 340 of the Public Health Service 

18 Act. 

19 (f) CONFORMING AMENDMENT.—Paragraph (4) of 

20 section 3014(h) of title 18, United States Code, is amend21 ed by striking ‘‘and section 2321(d) of the Continuing Ap22 propriations Act, 2024 and Other Extensions Act’’ and in23 serting ‘‘section 2321(d) of the Continuing Appropriations 

24 Act, 2024 and Other Extensions Act, and section 301(e) 

25 of the Lower Costs, More Transparency Act’’. 
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1 SEC. 302. EXTENSION OF SPECIAL DIABETES PROGRAMS. 

2 (a) EXTENSION OF SPECIAL DIABETES PROGRAMS

3 FOR TYPE I DIABETES.—Section 330B(b)(2) of the Pub4 lic Health Service Act (42 U.S.C. 254c–2(b)(2)) is amend5 ed— 

6 (1) in subparagraph (D), by striking ‘‘and’’ at 

7 the end; 

8 (2) in subparagraph (E), by striking the period 

9 at the end and inserting a semicolon; and 

10 (3) by adding at the end the following: 

11 ‘‘(F) $124,383,562 for the period begin12 ning on January 20, 2024, and ending on Sep13 tember 30, 2024, to remain available until ex14 pended; 

15 ‘‘(G) $170,000,000 for fiscal year 2025, to 

16 remain available until expended; and 

17 ‘‘(H) $42,849,315 for the period beginning 

18 October 1, 2025, and ending December 31, 

19 2025, to remain available until expended.’’. 

20 (b) EXTENDING FUNDING FOR SPECIAL DIABETES

21 PROGRAMS FOR INDIANS.—Section 330C(c)(2) of the 

22 Public Health Service Act (42 U.S.C. 254c–3(c)(2)) is 

23 amended— 

24 (1) in subparagraph (D), by striking ‘‘and’’ at 

25 the end; 
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1 (2) in subparagraph (E), by striking the period 

2 at the end and inserting a semicolon; and 

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

4 ‘‘(F) $124,383,562 for the period begin5 ning on January 20, 2024, and ending on Sep6 tember 30, 2024, to remain available until ex7 pended; 

8 ‘‘(G) $170,000,000 for fiscal year 2025, to 

9 remain available until expended; and 

10 ‘‘(H) $42,849,315 for the period beginning 

11 October 1, 2025, and ending December 31, 

12 2025, to remain available until expended.’’. 

13 SEC. 303. DELAYING CERTAIN DISPROPORTIONATE SHARE 

14 PAYMENT CUTS. 

15 Section 1923(f)(7)(A) of the Social Security Act (42 

16 U.S.C. 1396r–4(f)(7)(A)) is amended— 

17 (1) in clause (i)— 

18 (A) by striking ‘‘For the period beginning 

19 January 20, 2024, and ending September 30, 

20 2024, and for each of fiscal years 2025’’ and 

21 inserting ‘‘For each of fiscal years 2026’’; and 

22 (B) by striking ‘‘or period’’ each place 

23 such term appears; and 

24 (2) in clause (ii), by striking ‘‘for the period be25 ginning January 20, 2024, and ending September 
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1 30, 2024, and for each of fiscal years 2025’’ and in2 serting ‘‘for each of fiscal years 2026’’. 

3 SEC. 304. MEDICAID IMPROVEMENT FUND. 

4 Section 1941(b)(3)(A) of the Social Security Act (42 

5 U.S.C. 1396w–1(b)(3)(A)) is amended by striking ‘‘ 

6 $6,357,117,810’’ and inserting ‘‘$0’’. 

7 TITLE IV—INCREASING ACCESS 

8 TO QUALITY HEALTH DATA 

9 AND LOWERING HIDDEN 

10 FEES 

11 SEC. 401. INCREASING PLAN FIDUCIARIES’ ACCESS TO 

12 HEALTH DATA. 

13 (a) PLAN FIDUCIARY ACCESS TO INFORMATION.— 

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

15 408(b) of the Employee Retirement Income Security 

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

17 adding at the end the following new subparagraph: 

18 ‘‘(C) No contract or arrangement for services 

19 between a group health plan and any other entity, 

20 including a health care provider (including a health 

21 care facility), network or association of providers, 

22 service provider offering access to a network of pro23 viders, third-party administrator, or pharmacy ben24 efit manager, is reasonable within the meaning of 
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1 this paragraph unless such contract or arrange2 ment— 

3 ‘‘(i) allows the responsible plan fiduciary 

4 (as defined in subparagraph (B)(ii)(I)(ee)) to 

5 audit or review all de-identified claims and en6 counter information or data described in section 

7 724(a)(1)(B) to— 

8 ‘‘(I) ensure that such entity complies 

9 with the terms of the plan and any appli10 cable law; and 

11 ‘‘(II) determine the reasonableness of 

12 compensation received by such entity; and 

13 ‘‘(ii) does not— 

14 ‘‘(I) unreasonably limit the number of 

15 audits permitted during a given period of 

16 time; 

17 ‘‘(II) limit the number of de-identified 

18 claims and encounter information or data 

19 that the responsible plan fiduciary may ac20 cess during an audit; 

21 ‘‘(III) limit the disclosure of pricing 

22 terms for value-based payment arrange23 ments or capitated payment arrangements, 

24 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 (2) CIVIL ENFORCEMENT.— 

7 (A) IN GENERAL.—Subsection (c) of sec8 tion 502 of such Act (29 U.S.C. 1132) is 

9 amended by adding at the end the following 

10 new paragraph: 

11 ‘‘(13) In the case of an agreement between a group 

12 health plan and a health care provider (including a health 

13 care facility), network or association of providers, service 

14 provider offering access to a network of providers, third15 party administrator, or pharmacy benefit manager, that 

16 violates the provisions of section 724, the Secretary may 

17 assess a civil penalty against such provider, network or 

18 association, service provider offering access to a network 

19 of providers, third-party administrator, pharmacy benefit 

20 manager, or other service provider in the amount of 

21 $10,000 for each day during which such violation con22 tinues. Such penalty shall be in addition to other penalties 

23 as may be prescribed by law.’’. 

24 (B) CONFORMING AMENDMENT.—Para25 graph (6) of section 502(a) of such Act is 
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1 amended by striking ‘‘or (9)’’ and inserting 

2 ‘‘(9), or (13)’’. 

3 (3) EXISTING PROVISIONS VOID.—Section 410 

4 of such Act is amended by adding at the end the fol5 lowing new subsection: 

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

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

8 ‘‘(1) unduly delays or limits a plan fiduciary 

9 from accessing the de-identified claims and encoun10 ter information or data described in section 

11 724(a)(1)(B); or 

12 ‘‘(2) violates the requirements of section 

13 408(b)(2)(C).’’. 

14 (b) UPDATED ATTESTATION FOR PRICE AND QUAL15 ITY INFORMATION.—Section 724(a)(3) of the Employee 

16 Retirement Income Security Act (29 U.S.C. 1185m(a)(3)) 

17 is amended to read as follows: 

18 ‘‘(3) ATTESTATION.— 

19 ‘‘(A) IN GENERAL.—Subject to subpara20 graph (C), the plan fiduciary of a group health 

21 plan or health insurance issuer offering group 

22 health insurance coverage shall annually submit 

23 to the Secretary an attestation that such plan 

24 or issuer of such coverage is in compliance with 

25 the requirements of this subsection. Such attes-
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1 tation shall also include a statement verifying 

2 that— 

3 ‘‘(i) the information or data described 

4 under subparagraphs (A) and (B) of para5 graph (1) is available upon request and 

6 provided to the plan fiduciary, the plan ad7 ministrator, or the issuer in a timely man8 ner; and 

9 ‘‘(ii) there are no terms in the agree10 ment under such paragraph (1) that di11 rectly or indirectly restrict or unduly delay 

12 a plan fiduciary, the plan administrator, or 

13 the issuer from auditing, reviewing, or oth14 erwise accessing such information, except 

15 as permitted under section 408(b)(2)(C). 

16 ‘‘(B) LIMITATION ON SUBMISSION.—Sub17 ject to clause (ii), a group health plan or issuer 

18 offering group health insurance coverage may 

19 not enter into an agreement with a third-party 

20 administrator or other service provider to sub21 mit the attestation required under subpara22 graph (A). 

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

24 health plan or issuer offering group health in25 surance coverage that is unable to obtain the 
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1 information or data needed to submit the attes2 tation required under subparagraph (A), such 

3 plan or issuer may submit a written statement 

4 in lieu of such attestation that includes— 

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

6 or issuer was unsuccessful in obtaining 

7 such information or data, including wheth8 er such plan or issuer was limited or pre9 vented from auditing, reviewing, or other10 wise accessing such information or data; 

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

12 by the plan fiduciary to remove any gag 

13 clause provisions from the agreement 

14 under paragraph (1); and 

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

16 the third-party administrator or other serv17 ice provider with respect to efforts to com18 ply with the attestation requirement under 

19 subparagraph (A).’’. 

20 (c) REPORT ON PLAN ASSETS.—Not later than 1 

21 year after the date of enactment of this Act, the Secretary 

22 of Labor shall submit to the Committee on Education and 

23 the Workforce of the House of Representatives and the 

24 Committee on Health, Education, Labor, and Pensions of 

25 the Senate a report on the status of de-identified claims 
219 

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1 and encounter information or data described in section 

2 724(a)(1)(B) of the Employee Retirement Income Secu3 rity Act of 1974 (29 U.S.C. 1185m), including informa4 tion on the following: 

5 (1) Whether changes to regulations or guidance 

6 would permit such information or data to be deemed 

7 a group health plan asset (as defined under section 

8 3(42) of such Act). 

9 (2) Whether restrictions on the ability of a plan 

10 fiduciary to access such information or data violates 

11 a requirement of current law. 

12 (3) The existing regulatory authority of the 

13 Secretary to clarify whether such information or 

14 data is the property of a group health plan, rather 

15 than a service provider. 

16 (4) Legislative recommendations to establish 

17 that such information or data related to a plan be18 longs to a group health plan and is handled in the 

19 best interests of plan participants and beneficiaries. 

20 (d) EFFECTIVE DATE.—The amendments made by 

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

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

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

24 Act. 
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1 SEC. 402. HIDDEN FEES DISCLOSURE REQUIREMENTS. 

2 (a) CLARIFICATION OF THE APPLICATION OF FEE

3 DISCLOSURE REQUIREMENTS TO COVERED SERVICE PRO4 VIDERS.— 

5 (1) SERVICES.—Clause (ii)(I)(bb) of section 

6 408(b)(2)(B) of the Employee Retirement Income 

7 Security Act of 1974 (29 U.S.C. 1108(b)(2)(B)) is 

8 amended— 

9 (A) in subitem (AA) by striking ‘‘Broker10 age services,’’ and inserting ‘‘Services (includ11 ing brokerage services),’’; and 

12 (B) in subitem (BB)— 

13 (i) by striking ‘‘Consulting,’’ and in14 serting ‘‘Other services,’’; and 

15 (ii) by inserting ‘‘any of the fol16 lowing:’’ before ‘‘plan design’’. 

17 (2) DISCLOSURES.—Clause (iii)(III) of section 

18 408(b)(2)(B) of the Employee Retirement Income 

19 Security Act of 1974 (29 U.S.C. 1108(b)(2)(B)) is 

20 amended by striking ‘‘, either in the aggregate or by 

21 service,’’ and inserting ‘‘by service’’. 

22 (b) STRENGTHENING DISCLOSURE REQUIREMENTS

23 WITH RESPECT TO PHARMACY BENEFIT MANAGERS AND

24 THIRD PARTY ADMINISTRATORS FOR GROUP HEALTH

25 PLANS.— 
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1 (1) CERTAIN ARRANGEMENTS FOR PHARMACY

2 BENEFIT MANAGER SERVICES CONSIDERED AS INDI3 RECT.— 

4 (A) IN GENERAL.—Clause (i) of section 

5 408(b)(2)(B) of the Employee Retirement In6 come Security Act of 1974 (29 U.S.C. 

7 1108(b)(2)(B)) is amended— 

8 (i) by striking ‘‘requirements of this 

9 clause’’ and inserting ‘‘requirements of this 

10 subparagraph’’; and 

11 (ii) by adding at the end the fol12 lowing: ‘‘For purposes of applying section 

13 406(a)(1)(C) with respect to a transaction 

14 described under this subparagraph, a con15 tract or arrangement for services between 

16 a covered plan and a health insurance 

17 issuer providing health insurance coverage 

18 in connection with the covered plan in 

19 which the health insurance issuer con20 tracts, in connection with such plan, with 

21 a service provider for pharmacy benefit 

22 management services shall be considered to 

23 constitute an indirect furnishing of goods, 

24 services, or facilities between the plan and 
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1 the service provider acting as the party in 

2 interest.’’. 

3 (B) HEALTH INSURANCE ISSUER AND

4 HEALTH INSURANCE COVERAGE DEFINED.— 

5 Clause (ii)(I)(aa) of section 408(b)(2)(B) of 

6 such Act (29 U.S.C. 1108(b)(2)(B)) is amended 

7 by inserting before the period at the end ‘‘and 

8 the terms ‘health insurance coverage’ and 

9 ‘health insurance issuer’ have the meanings 

10 given such terms in section 733(b)’’. 

11 (C) TECHNICAL AMENDMENT.—Clause 

12 (ii)(I)(aa) of section 408(b)(2)(B) of the Em13 ployee Retirement Income Security Act of 1974 

14 (29 U.S.C. 1108(b)(2)(B)) is further amended 

15 by inserting ‘‘in’’ after ‘‘defined’’. 

16 (2) SPECIFIC DISCLOSURE REQUIREMENTS

17 WITH RESPECT TO PHARMACY BENEFIT MANAGE18 MENT SERVICES.— 

19 (A) IN GENERAL.—Clause (iii) of section 

20 408(b)(2)(B) of such Act (29 U.S.C. 

21 1108(b)(2)(B)) is amended by adding at the 

22 end the following: 

23 ‘‘(VII) With respect to a contract or ar24 rangement with the covered plan in connection 

25 with the provision of pharmacy benefit manage-
223 

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1 ment services, as part of the description re2 quired under subclauses (III) and (IV)— 

3 ‘‘(aa) all compensation described in 

4 clause (ii)(I)(dd)(AA), including fees, re5 bates, alternative discounts, co-payment 

6 offsets, and other remuneration expected 

7 to be received by the covered service pro8 vider, an affiliate, or a subcontractor from 

9 a pharmaceutical manufacturer, dis10 tributor, rebate aggregator, accumulator, 

11 and maximizer, group purchasing organiza12 tion, or any other third party; 

13 ‘‘(bb) the amount and form of any re14 bates, discounts, or price concessions, in15 cluding the amount expected to be passed 

16 through to the plan sponsor or the partici17 pants and beneficiaries under the covered 

18 plan; 

19 ‘‘(cc) all compensation expected to be 

20 received by the covered service provider, an 

21 affiliate, or a subcontractor as a result of 

22 paying a lower amount for the drug than 

23 the amount charged as a copayment, coin24 surance amount, or deductible; 
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1 ‘‘(dd) all compensation expected to be 

2 received by the covered service provider, an 

3 affiliate, or a subcontractor as a result of 

4 paying pharmacies less than what is 

5 charged the health plan, plan sponsor, or 

6 participants and beneficiaries under the 

7 covered plan; and 

8 ‘‘(ee) all compensation expected to be 

9 received by the covered service provider, an 

10 affiliate, or a subcontractor from drug 

11 manufacturers and any other third party 

12 in exchange for— 

13 ‘‘(AA) administering, invoicing, 

14 allocating, or collecting rebates related 

15 to the covered plan; 

16 ‘‘(BB) providing business serv17 ices and activities, including providing 

18 access to drug utilization data; 

19 ‘‘(CC) keeping a percentage of 

20 the list price of a drug; or 

21 ‘‘(DD) any other reason related 

22 to the role of a covered service pro23 vider as a conduit between the drug 

24 manufacturers or any other third 

25 party and the covered plan.’’. 
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1 (B) ANNUAL DISCLOSURE.—Clause (v) of 

2 section 408(b)(2)(B) of such Act (29 U.S.C. 

3 1108(b)(2)(B)) is amended by adding at the 

4 end the following: 

5 ‘‘(III) A covered service provider, with re6 spect to a contract or arrangement with the 

7 covered plan in connection with providing phar8 macy benefit management services, shall dis9 close, on an annual basis not later than 60 days 

10 after the beginning of the current plan year, to 

11 a responsible plan fiduciary, in writing, the fol12 lowing with respect to the twelve months pre13 ceding the current plan year: 

14 ‘‘(aa) All direct compensation de15 scribed in subclause (III) of clause (iii) 

16 and indirect compensation described in 

17 subclause (IV) of clause (iii) received by 

18 the covered service provider (including 

19 such compensation described in subclause 

20 (VII) of clause (iii)). 

21 ‘‘(bb) The total gross spending by the 

22 covered plan on drugs (excluding rebates, 

23 discounts, or other price concessions). 

24 ‘‘(cc) The total net spending by the 

25 covered plan on drugs. 
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1 ‘‘(dd) The total gross spending at all 

2 pharmacies wholly or partially owned by 

3 the covered service provider or any entity 

4 affiliated with the covered service provider, 

5 including mail-order, specialty and retail 

6 pharmacies, with a breakdown by indi7 vidual pharmacy location. 

8 ‘‘(ee) The aggregate amount of 

9 clawback from such pharmacies, including 

10 mail-order, specialty, and retail phar11 macies. 

12 ‘‘(AA) categorical explanations 

13 (grouped by the reason for clawback, 

14 such as contractual true-up provi15 sions, overpayments, or non-covered 

16 medication dispensed, and including 

17 information on the amount in each 

18 category that was passed through to 

19 the covered plan and to participants 

20 and beneficiaries of the covered plan); 

21 or 

22 ‘‘(BB) individual explanations for 

23 such clawbacks. 

24 ‘‘(ff) Total aggregate amounts of fees 

25 collected by the covered service provider, 
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1 an affiliate, or a subcontractor in connec2 tion with the provision of pharmacy benefit 

3 management services to the covered plan. 

4 ‘‘(gg) Any other information specified 

5 by the Secretary through regulations or 

6 guidance that may be necessary for a re7 sponsible plan fiduciary to consider the 

8 merits of the contract or arrangement with 

9 the covered service provider and any con10 flicts of interest that may exist.’’. 

11 (C) PHARMACY BENEFIT MANAGEMENT

12 SERVICES DEFINED.—Clause (ii)(I) of section 

13 408(b)(2)(B) of such Act (29 U.S.C. 

14 1108(b)(2)(B)) is amended by adding at the 

15 end the following: 

16 ‘‘(gg) The term ‘pharmacy benefit 

17 management services’ includes any services 

18 provided by a covered service provider to a 

19 covered plan with respect to the adminis20 tration of prescription drug benefits under 

21 the covered plan, including— 

22 ‘‘(AA) processing and payment of 

23 claims; 

24 ‘‘(BB) design of pharmacy net25 works; 
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1 ‘‘(CC) negotiation, aggregation, 

2 and distribution of rebates, discounts, 

3 and other price concessions; 

4 ‘‘(DD) formulary design and 

5 maintenance; 

6 ‘‘(EE) operation of pharmacies 

7 (whether retail, mail order, specialty 

8 drug, or otherwise); 

9 ‘‘(FF) recordkeeping; 

10 ‘‘(GG) utilization review; 

11 ‘‘(HH) adjudication of claims; 

12 and 

13 ‘‘(II) any other services specified 

14 by the Secretary through guidance or 

15 rulemaking.’’. 

16 (D) CLAWBACK DEFINED.—Clause (ii)(I) 

17 of section 408(b)(2)(B) of such Act (29 U.S.C. 

18 1108(b)(2)(B)), as amended by subparagraph 

19 (C), is amended by adding at the end the fol20 lowing: 

21 ‘‘(hh) The term ‘clawback’ means 

22 amounts collected by a provider of phar23 macy benefit management services from a 

24 pharmacy for copayments collected from a 
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1 participant or beneficiary in excess of the 

2 contracted rate.’’. 

3 (3) SPECIFIC DISCLOSURE REQUIREMENTS

4 WITH RESPECT TO THIRD PARTY ADMINISTRATION

5 SERVICES FOR GROUP HEALTH PLANS.— 

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)), as amended by paragraph 

9 (2)(A), is further amended by adding at the end 

10 the following: 

11 ‘‘(VIII) With respect to a contract or ar12 rangement with the covered plan in connection 

13 with the provision of third party administration 

14 services for group health plans, as part of the 

15 description required under subclauses (III) and 

16 (IV)— 

17 ‘‘(aa) the amount and form of any re18 bates, discounts, savings fees, refunds, or 

19 amounts received from providers and facili20 ties, including the amounts that will be re21 tained by the covered service provider as a 

22 fee; 

23 ‘‘(bb) the amount and form of fees ex24 pected to be received from other service 

25 providers in relation to the covered plan, 
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1 including the amounts that will be retained 

2 by the covered service provider as a fee; 

3 and 

4 ‘‘(cc) the amount and form of ex5 pected recoveries by the covered service 

6 provider, including the amounts that will 

7 be retained by the covered service provider 

8 as a fee (disaggregated by category), as a 

9 result of— 

10 ‘‘(AA) overpayments; 

11 ‘‘(BB) erroneous payments; 

12 ‘‘(CC) uncashed checks or incom13 plete payments; 

14 ‘‘(DD) billing errors; 

15 ‘‘(EE) subrogation; 

16 ‘‘(FF) fraud; or 

17 ‘‘(GG) any other reason on behalf 

18 of the covered plan.’’. 

19 (B) ANNUAL DISCLOSURE.—Clause (v) of 

20 section 408(b)(2)(B) of such Act (29 U.S.C. 

21 1108(b)(2)(B)), as amended by paragraph 

22 (2)(B), is amended by adding at the end the 

23 following: 

24 ‘‘(IV) A covered service provider, with re25 spect to a contract or arrangement with the 
231 

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1 covered plan in connection with providing third 

2 party administration services for group health 

3 plans, shall disclose, on an annual basis not 

4 later than 60 days after the beginning of the 

5 current plan year, to a responsible plan fidu6 ciary, in writing, the following with respect to 

7 the twelve months preceding the current plan 

8 year: 

9 ‘‘(aa) All direct compensation de10 scribed in subclause (III) of clause (iii). 

11 ‘‘(bb) All indirect compensation de12 scribed in subclause (IV) of clause (iii) re13 ceived by the covered service provider, an 

14 affiliate, or a subcontractor (including such 

15 compensation described in subclause (VIII) 

16 of clause (iii)). 

17 ‘‘(cc) The aggregate amount for which 

18 the covered service provider, an affiliate, or 

19 a subcontractor received indirect com20 pensation and the estimated amount of 

21 cost-sharing incurred by plan participants 

22 and beneficiaries as a result. 

23 ‘‘(dd) The total gross spending by the 

24 covered plan on all costs and fees arising 

25 under or paid under the administrative 
232 

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1 services agreement with the covered service 

2 provider (not including any amounts de3 scribed in items (aa) through (cc) of clause 

4 (iii)(VIII)). 

5 ‘‘(ee) The total net spending by the 

6 covered plan on all costs and fees arising 

7 under or paid under the administrative 

8 services agreement with the covered service 

9 provider. 

10 ‘‘(ff) The aggregate fees collected by 

11 the covered service provider, an affiliate, or 

12 a subcontractor. 

13 ‘‘(gg) Any other information specified 

14 by the Secretary through regulations or 

15 guidance that may be necessary for a re16 sponsible plan fiduciary to consider the 

17 merits of the contract or arrangement with 

18 the covered service provider and any con19 flicts of interest that may exist.’’. 

20 (C) THIRD PARTY ADMINISTRATION SERV21 ICES FOR GROUP HEALTH PLANS DEFINED.— 

22 Clause (ii)(I) of section 408(b)(2)(B) of such 

23 Act (29 U.S.C. 1108(b)(2)(B)), as amended by 

24 paragraph (2)(C), is amended by adding at the 

25 end the following: 
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1 ‘‘(ii) The term ‘third party adminis2 tration services for group health plans’ in3 cludes any services provided by a covered 

4 service provider, an affiliate, or a subcon5 tractor to a covered plan with respect to 

6 the administration of health benefits under 

7 the covered plan, including— 

8 ‘‘(AA) the processing, repricing, 

9 and payment of claims; 

10 ‘‘(BB) design, creation, and 

11 maintenance of provider networks; 

12 ‘‘(CC) negotiation of discounts 

13 off gross rates; 

14 ‘‘(DD) benefit and plan design; 

15 ‘‘(EE) negotiation of payment 

16 rates; 

17 ‘‘(FF) recordkeeping; 

18 ‘‘(GG) utilization review; 

19 ‘‘(HH) adjudication of claims; 

20 ‘‘(II) regulatory compliance; and 

21 ‘‘(JJ) any other services set forth 

22 in an administrative services agree23 ment or similar agreement or specified 

24 by the Secretary through rule25 making.’’. 
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1 (4) RULE OF CONSTRUCTION.—Nothing in the 

2 amendments made by this section shall be construed 

3 to imply that a practice in relation to which a cov4 ered service provider is required to provide informa5 tion as a result of such amendments is permissible 

6 under Federal law. 

7 (5) EFFECTIVE DATE.—No contract or ar8 rangement entered into prior to January 1, 2025, 

9 shall be subject to the requirements of subsection 

10 (b). 

11 (c) PRIVACY REQUIREMENTS.—Section 408(b)(2) of 

12 the Employee Retirement Income Security Act of 1974 

13 (29 U.S.C. 1108(b)(2)), as amended by section 401, is 

14 further amended by adding at the end the following: 

15 ‘‘(D) PRIVACY REQUIREMENTS.—Covered serv16 ice providers shall provide information under sub17 paragraph (B) in a manner consistent with the pri18 vacy, security, and breach notification regulations 

19 promulgated under section 13402(a) of the Health 

20 Information Technology for Clinical Health Act (42 

21 U.S.C. 17932(a)), and consistent with the HIPAA 

22 privacy regulations (as defined in section 1180(b)(3) 

23 of the Social Security Act) and shall restrict the use 

24 and disclosure of such information according to such 
235 

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1 privacy, security, and breach notification regulations 

2 and such HIPAA privacy regulations. 

3 ‘‘(E) DISCLOSURE AND REDISCLOSURE.— 

4 ‘‘(i) LIMITATION TO BUSINESS ASSOCI5 ATES.—A responsible plan fiduciary receiving 

6 information disclosed under subparagraph (B) 

7 may disclose such information only to the entity 

8 from which the information was received, the 

9 group health plan for which the information 

10 pertains, or to that entity’s business associates 

11 as defined in section 160.103 of title 45, Code 

12 of Federal Regulations (or successor regula13 tions) or as permitted by the HIPAA Privacy 

14 Rule (45 CFR parts 160 and 164, subparts A 

15 and E). 

16 ‘‘(ii) CLARIFICATION REGARDING PUBLIC

17 DISCLOSURE OF INFORMATION.—Nothing in 

18 this section shall prevent a group health plan or 

19 health insurance issuer offering group health 

20 insurance coverage, or a covered service pro21 vider, from placing reasonable restrictions on 

22 the public disclosure of the information de23 scribed in this subparagraph, except that such 

24 plan, issuer, or entity may not restrict disclo-
236 

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1 sure of such information to the Department of 

2 Labor. 

3 ‘‘(F) ADDITIONAL PRIVACY REQUIREMENTS.— 

4 ‘‘(i) IN GENERAL.—Covered service pro5 viders shall ensure that information provided 

6 under subparagraph (B) contains only summary 

7 health information, as defined in section 

8 164.504(a) of title 45, Code of Federal Regula9 tions (or successor regulations). 

10 ‘‘(ii) RESTRICTIONS.—A group health plan 

11 must comply with section 164.504(f) of title 45, 

12 Code of Federal Regulations and a responsible 

13 plan administrator who is a plan sponsor must 

14 act in accordance with the terms of the agree15 ment described in such section. 

16 ‘‘(G) RULE OF CONSTRUCTION.—Nothing in 

17 this section shall be construed to modify the require18 ments for the creation, receipt, maintenance, or 

19 transmission of protected health information under 

20 the HIPAA privacy regulations (as defined in sec21 tion 1180(b)(3) of the Social Security Act).’’. 

22 (d) IMPLEMENTATION.—Not later than 1 year after 

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

24 shall issue notice and comment rulemaking as necessary 
237 

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1 to implement the provisions of this section. The Secretary 

2 shall ensure that such rulemaking— 

3 (1) accounts for the varied compensation prac4 tices of covered service providers (as defined under 

5 section 408(b)(2)(B); and 

6 (2) establishes standards for the disclosure of 

7 expected compensation by such covered service pro8 viders. 

9 SEC. 403. PRESCRIPTION DRUG PRICE INFORMATION RE10 QUIREMENT. 

11 (a) PHSA.— 

12 (1) IN GENERAL.—Part D of title XXVII of the 

13 Public Health Service Act, as amended by section 

14 106, is further amended by adding at the end the 

15 following new section: 

16 ‘‘SEC. 2799A–12. INFORMATION ON PRESCRIPTION DRUGS. 

17 ‘‘(a) IN GENERAL.—A group health plan or a health 

18 insurance issuer offering group or individual health insur19 ance coverage shall— 

20 ‘‘(1) not restrict, directly or indirectly, any 

21 pharmacy that dispenses a prescription drug to an 

22 enrollee in the plan or coverage from informing (or 

23 penalize such pharmacy for informing) an enrollee of 

24 any differential between the enrollee’s out-of-pocket 

25 cost under the plan or coverage with respect to ac-
238 

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1 quisition of the drug and the amount an individual 

2 would pay for acquisition of the drug without using 

3 any group health plan or health insurance coverage; 

4 and 

5 ‘‘(2) ensure that any entity that provides phar6 macy benefits management services under a contract 

7 with any such health plan or health insurance cov8 erage does not, with respect to such plan or cov9 erage, restrict, directly or indirectly, a pharmacy 

10 that dispenses a prescription drug from informing 

11 (or penalize such pharmacy for informing) an en12 rollee of any differential between the enrollee’s out13 of-pocket cost under such plan or coverage with re14 spect to acquisition of the drug and the amount an 

15 individual would pay for acquisition of the drug 

16 without using any group health plan or health insur17 ance 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 enrollee under 

21 the plan or coverage, including any cost-sharing (including 

22 any deductible, copayment, or coinsurance) and, as deter23 mined by the Secretary, any other expenditure.’’. 

24 (2) CONFORMING AMENDMENT.—Section 2729 

25 of the Public Health Service Act (42 U.S.C. 300gg– 
239 

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1 29) is amended by adding at the end the following 

2 new subsection: 

3 ‘‘(c) SUNSET.—The preceding provisions of this sec4 tion shall not apply beginning on the date of the enact5 ment of this subsection.’’. 

6 (b) ERISA.— 

7 (1) IN GENERAL.—Subpart B of part 7 of Sub8 title B of title I of the Employee Retirement Income 

9 Security Act of 1974 (29 U.S.C. 1185 et seq.), as 

10 amended by section 106, is further amended by add11 ing at the end the following new section: 

12 ‘‘SEC. 727. INFORMATION ON PRESCRIPTION DRUGS. 

13 ‘‘(a) IN GENERAL.—A group health plan or a health 

14 insurance issuer offering group health insurance coverage 

15 shall— 

16 ‘‘(1) not restrict, directly or indirectly, any 

17 pharmacy that dispenses a prescription drug to a 

18 participant or beneficiary in the plan or coverage 

19 from informing (or penalize such pharmacy for in20 forming) a participant or beneficiary of any differen21 tial between the participant’s or beneficiary’s out-of22 pocket cost under the plan or coverage with respect 

23 to acquisition of the drug and the amount an indi24 vidual would pay for acquisition of the drug without 
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1 using any group health plan or health insurance cov2 erage; and 

3 ‘‘(2) ensure that any entity that provides phar4 macy benefits management services under a contract 

5 with any such health plan or health insurance cov6 erage does not, with respect to such plan or cov7 erage, restrict, directly or indirectly, a pharmacy 

8 that dispenses a prescription drug from informing 

9 (or penalize such pharmacy for informing) a partici10 pant or beneficiary of any differential between the 

11 participant’s or beneficiary’s out-of-pocket cost 

12 under such plan or coverage with respect to acquisi13 tion of the drug and the amount an individual would 

14 pay for acquisition of the drug without using any 

15 group health plan or health insurance coverage. 

16 ‘‘(b) DEFINITION.—For purposes of this section, the 

17 term ‘out-of-pocket cost’, with respect to acquisition of a 

18 drug, means the amount to be paid by the participant or 

19 beneficiary under the plan or coverage, including any cost20 sharing (including any deductible, copayment, or coinsur21 ance) and, as determined by the Secretary, any other ex22 penditure.’’. 

23 (2) CLERICAL AMENDMENT.—The table of con24 tents in section 1 of the Employee Retirement In25 come Security Act of 1974 (29 U.S.C. 1001 et seq.), 
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1 as amended by section 106, is further amended by 

2 inserting after the item relating to section 726 the 

3 following new item: 

‘‘Sec. 727. Information on prescription drugs.’’. 

4 (c) IRC.— 

5 (1) IN GENERAL.—Subchapter B of chapter 

6 100 of the Internal Revenue Code of 1986, as 

7 amended by section 106, is further amended by add8 ing at the end the following: 

9 ‘‘SEC. 9827. INFORMATION ON PRESCRIPTION DRUGS. 

10 ‘‘(a) IN GENERAL.—A group health plan shall— 

11 ‘‘(1) not restrict, directly or indirectly, any 

12 pharmacy that dispenses a prescription drug to a 

13 participant or beneficiary in the plan from informing 

14 (or penalize such pharmacy for informing) a partici15 pant or beneficiary of any differential between the 

16 participant’s or beneficiary’s out-of-pocket cost 

17 under the plan with respect to acquisition of the 

18 drug and the amount an individual would pay for ac19 quisition of the drug without using any group health 

20 plan or health insurance coverage; and 

21 ‘‘(2) ensure that any entity that provides phar22 macy benefits management services under a contract 

23 with any such plan does not, with respect to such 

24 plan or coverage, restrict, directly or indirectly, a 

25 pharmacy that dispenses a prescription drug from 
242 

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1 informing (or penalize such pharmacy for informing) 

2 a participant or beneficiary of any differential be3 tween the participant’s or beneficiary’s out-of-pocket 

4 cost under the plan with respect to acquisition of the 

5 drug and the amount an individual would pay for ac6 quisition of the drug without using any group health 

7 plan or health insurance coverage. 

8 ‘‘(b) DEFINITION.—For purposes of this section, the 

9 term ‘out-of-pocket cost’, with respect to acquisition of a 

10 drug, means the amount to be paid by the participant or 

11 beneficiary under the plan, including any cost-sharing (in12 cluding any deductible, copayment, or coinsurance) and, 

13 as determined by the Secretary, any other expenditure.’’. 

14 (2) CLERICAL AMENDMENT.—The table of sec15 tions for subchapter B of chapter 100 of the Inter16 nal Revenue Code of 1986, as amended by section 

17 106, is further amended by adding at the end the 

18 following new item: 

‘‘Sec. 9827. Information on prescription drugs.’’. 

19 SEC. 404. IMPLEMENTATION FUNDING. 

20 (a) IN GENERAL.—For the purposes described in 

21 subsection (b), and in addition to amounts otherwise avail22 able for such purposes there are appropriated, out of 

23 amounts in the Treasury not otherwise appropriated, to 

24 the Secretary of Labor $35,000,000, for fiscal year 2024, 

25 to remain available through fiscal year 2029. 
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1 (b) PERMITTED PURPOSES.—The purposes described 

2 in this subsection are limited to the following purposes, 

3 insofar as such purposes are to carry out the provisions 

4 of, including the amendments made by, title I and IV: 

5 (1) Preparing, drafting, and issuing proposed 

6 and final regulations or interim regulations. 

7 (2) Preparing, drafting, and issuing guidance 

8 and public information. 

9 (3) Preparing, drafting, and publishing reports. 

10 (4) Enforcement of such provisions. 

11 (5) Reporting, collection, and analysis of data. 

12 (6) Other administrative duties necessary for 

13 implementation of such provisions. 

14 (c) TRANSPARENCY OF IMPLEMENTATION FUNDS.— 

15 The Secretary of Labor shall annually submit, no later 

16 than September 1st of each year, to the Committees on 

17 Education and Workforce and on Appropriations of the 

18 House of Representatives and the Committees on Health, 

19 Education, Labor, and Pensions and on Appropriations of 
244 

•HR 5378 EH

1 the Senate a report on funds expended pursuant to funds 

2 appropriated under this section. 

Passed the House of Representatives December 11, 

2023. 

Attest: 

Clerk. 

118TH CONGRESS 

1ST SESSION H. R. 5378 

AN ACT 

To promote price transparency in the health care 

sector, and for other purposes.