Transparent PRICE Act

Subjects: Health


<html><body><pre>[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2691 Introduced in House (IH)]

&lt;DOC&gt;






118th CONGRESS
  1st Session
                                H. R. 2691

          To promote hospital and insurer price transparency.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             April 18, 2023

Mrs. Rodgers of Washington (for herself and Mr. Pallone) introduced the 
   following bill; which was referred to the Committee on Energy and 
                                Commerce

_______________________________________________________________________

                                 A BILL


 
          To promote hospital and insurer price transparency.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Transparent Prices Required to 
Inform Consumer and Employers Act'' or the ``Transparent PRICE Act''.

SEC. 2. PRICE TRANSPARENCY REQUIREMENTS.

    (a) In General.--Section 2718(e) of the Public Health Service Act 
(42 U.S.C. 300gg-18(e)) is amended--
            (1) by striking ``Each hospital'' and inserting the 
        following:
            ``(1) In general.--Each hospital'';
            (2) by inserting ``, in plain language without subscription 
        and free of charge, in a consumer-friendly, machine-readable 
        format,'' after ``a list''; and
            (3) by adding at the end the following: ``Beginning January 
        1, 2024, each hospital shall include in its list of standard 
        charges, along with such additional information as the 
        Secretary may require with respect to such charges for purposes 
        of promoting public awareness of hospital pricing in advance of 
        receiving a hospital item or service, as applicable, the 
        following:
                    ``(A) A description of each item or service 
                provided by the hospital, accompanied by, as 
                applicable, the Current Procedural Terminology (CPT) 
                code, the Healthcare Common Procedure Coding System 
                (HCPCS) code, the Diagnosis Related Group (DRG), the 
                National Drug Code (NDC), or other payer identifier 
                used or approved by the Centers for Medicare & Medicaid 
                Services.
                    ``(B) The gross charge, expressed as a dollar 
                amount, for each such item or service, when provided 
                in, as applicable, the hospital inpatient setting and 
                outpatient department setting.
                    ``(C) Any current payer-specific negotiated 
                charges, clearly associated with the name of the third 
                party payer and plan and expressed as a dollar amount, 
                that applies to each item or service when provided in, 
                as applicable, the hospital inpatient setting and 
                outpatient department setting.
                    ``(D) The discounted cash price, expressed as a 
                dollar amount, for each such item or service when 
                provided in, as applicable, the hospital inpatient 
                setting and outpatient department setting. If the 
                discounted cash price is a percentage of another value 
                provided, the calculated value must be entered as a 
                dollar amount. If the discounted cash price equates to 
                the gross charge, the gross charge shall be re-entered 
                to indicate that no cash discount is available.
                    ``(E) The average negotiated rate and acquisition 
                cost paid by the hospital for each drug or biological 
                product--
                            ``(i) for which payment would be made under 
                        part B of title XVIII of the Social Security 
                        Act if the individual administered such drug or 
                        biological product were enrolled under such 
                        part B; and
                            ``(ii) that is administered by the hospital 
                        or an entity with a direct financial 
                        relationship to the hospital during the 
                        previous year,
                which, in the case of such a drug or biological product 
                that is first administered in the hospital during the 
                previous 12-month period, shall be included in such 
                list of standard charges beginning not later than 30 
                days after the date of such first administration.
            ``(2) Delivery methods and use.--
                    ``(A) In general.--Each hospital shall make public 
                the standard charges described in paragraph (1) for as 
                many of the 70 Centers for Medicare & Medicaid 
                Services-specified shoppable services that are provided 
                by the hospital, and as many additional hospital-
                selected shoppable services as may be necessary for a 
                combined total of at least 300 shoppable services, 
                including the rate at which a hospital provides and 
                bills for that shoppable service. If a hospital does 
                not provide 300 shoppable services in accordance with 
                the previous sentence, the hospital shall make public 
                the information specified under paragraph (1) for as 
                many shoppable services as it provides.
                    ``(B) Determination by cms.--With respect to a year 
                before 2025, a hospital shall be deemed by the Centers 
                for Medicare & Medicaid Services to meet the 
                requirements of subparagraph (A) if the hospital 
                maintains an internet-based price estimator tool that 
                meets the following requirements:
                            ``(i) The tool provides estimates for as 
                        many of the 70 specified shoppable services 
                        that are provided by the hospital, and as many 
                        additional hospital-selected shoppable services 
                        as may be necessary for a combined total of at 
                        least 300 shoppable services.
                            ``(ii) The tool allows health care 
                        consumers to, at the time they use the tool, 
                        obtain an estimate of the amount they will be 
                        obligated to pay the hospital for the shoppable 
                        service.
                            ``(iii) The tool is prominently displayed 
                        on the hospital's website and easily accessible 
                        to the public, without subscription, fee, or 
                        having to submit personal identifying 
                        information (PII), and searchable by service 
                        description, billing code, and payer.
            ``(3) Uniform method and format.--Not later than January 1, 
        2025, the Secretary shall implement a standard, uniform method 
        and format for hospitals to use in order to satisfy the 
        requirements of this subsection for disclosing directly to the 
        public charge and price information. Such method and format may 
        be similar to any template established by the Centers for 
        Medicare & Medicaid Services as of the date of the enactment of 
        this paragraph for reporting such information under this 
        subsection and shall meet such standards as determined 
        appropriate by the Secretary.
            ``(4) Monitoring of pricing information.--The Secretary, in 
        consultation with the Inspector General of the Department of 
        Health and Human Services, shall, through notice and comment 
        rulemaking, establish a process to regularly monitor the 
        accuracy and validity of pricing information displayed by each 
        hospital pursuant to paragraph (1).
            ``(5) Definitions.--Notwithstanding any other provision of 
        law, for the purpose of paragraphs (1) and (2):
                    ``(A) De-identified maximum negotiated charge.--The 
                term `de-identified maximum negotiated charge' means 
                the highest charge that a hospital has negotiated with 
                all third party payers for an item or service.
                    ``(B) De-identified minimum negotiated charge.--The 
                term `de-identified minimum negotiated charge' means 
                the lowest charge that a hospital has negotiated with 
                all third party payers for an item or service.
                    ``(C) Discounted cash price.--The term `discounted 
                cash price' means the charge that applies to an 
                individual who pays cash, or cash equivalent, for a 
                hospital item or service. Hospitals that do not offer 
                self-pay discounts may display the hospital's 
                undiscounted gross charges as found in the hospital 
                chargemaster.
                    ``(D) Gross charge.--The term `gross charge' means 
                the charge for an individual item or service that is 
                reflected on a hospital's chargemaster, absent any 
                discounts.
                    ``(E) Payer-specific negotiated charge.--The term 
                `payer-specific negotiated charge' means the charge 
                that a hospital has negotiated with a third party payer 
                for an item or service.
                    ``(F) Shoppable service.--The term `shoppable 
                service' means a service that can be scheduled by a 
                health care consumer in advance.
                    ``(G) Standard charges.--The term `standard 
                charges' means the regular rate established by the 
                hospital for an item or service, including both 
                individual items and services and service packages, 
                provided to a specific group of paying patients, 
                including the gross charge, the payer-specific 
                negotiated charge, the discounted cash price, the de-
                identified minimum negotiated charge, the de-identified 
                maximum negotiated charge, and other rates determined 
                by the Secretary.
                    ``(H) Third party payer.--The term `third party 
                payer' means an entity that is, by statute, contract, 
                or agreement, legally responsible for payment of a 
                claim for a health care item or service.
            ``(6) Enforcement.--
                    ``(A) In general.--In the case of a hospital that 
                fails to provide the information required by this 
                subsection--
                            ``(i) the Secretary shall notify such 
                        hospital of such failure not later than 30 days 
                        after the date on which the Secretary 
                        determines such failure exists; and
                            ``(ii) not later than 90 days after the 
                        date of such notification, the hospital shall 
                        complete a corrective action plan to comply 
                        with such requirements.
                    ``(B) Civil monetary penalty.--
                            ``(i) In general.--In addition to any other 
                        enforcement actions or penalties that may apply 
                        under subsection (b)(3) or another provision of 
                        law, a hospital that has received a 
                        notification under subparagraph (A)(i) and 
                        fails to satisfy the requirement under 
                        subparagraph (A)(ii) or otherwise comply with 
                        the requirements of this subsection not later 
                        than 90 days after such notification, shall be 
                        subject to a civil monetary penalty of an 
                        amount--
                                    ``(I) in the case the hospital 
                                provides not more than 30 beds (as 
                                determined under section 
                                180.90(c)(2)(ii)(D) of title 45, Code 
                                of Federal Regulations, as in effect on 
                                the date of the enactment of this 
                                paragraph), not to exceed $300 per day 
                                that the violation is ongoing as 
                                determined by the Secretary; and
                                    ``(II) in the case the hospital 
                                provides more than 30 beds (as so 
                                determined), equal to--
                                            ``(aa) subject to item 
                                        (bb), $10 per bed per day that 
                                        the violation is ongoing as 
                                        determined by the Secretary, 
                                        but for violations occurring 
                                        before January 1, 2024, not to 
                                        exceed $5,500 per each such 
                                        day; or
                                            ``(bb) in the case such 
                                        hospital has failed to satisfy 
                                        the requirement under 
                                        subparagraph (A)(ii) or 
                                        otherwise comply with the 
                                        requirements of this subsection 
                                        for any continuous 1-year 
                                        period beginning on or after 
                                        January 1, 2024, and the amount 
                                        otherwise imposed under item 
                                        (aa) for such failure for such 
                                        period would be less than 
                                        $5,000,000, an amount not less 
                                        than $5,000,000.
                            ``(ii) Increase authority.--In applying 
                        this subparagraph with respect to violations 
                        occurring in 2025 or a subsequent year, the 
                        Secretary may through notice and comment 
                        rulemaking increase any dollar amount applied 
                        under this subparagraph by an amount specified 
                        by the Secretary.
                            ``(iii) Application of certain 
                        provisions.--The provisions of section 1128A of 
                        the Social Security Act (other than subsections 
                        (a) and (b) of such section) shall apply to a 
                        civil monetary penalty imposed under clause (i) 
                        in the same manner as such provisions apply to 
                        a civil monetary penalty imposed under 
                        subsection (a) of such section.''.
    (b) Publication of List of Hospitals.--
            (1) List of hospitals.--Beginning not later than 90 days 
        after the date of enactment of this Act, the Secretary of 
        Health and Human Services (referred to in this section as the 
        ``Secretary'') shall establish and maintain a publicly 
        available list, on the website of the Centers for Medicare & 
        Medicaid Services and updated in real time, of--
                    (A) each hospital that--
                            (i) is not in compliance with the hospital 
                        price transparency rule implementing section 
                        2718(e) of the Public Health Service Act (42 
                        U.S.C. 300gg-18(e)), and that, with respect to 
                        such noncompliance--
                                    (I) has been issued a civil 
                                monetary penalty;
                                    (II) has received a warning notice; 
                                or
                                    (III) has received a request for a 
                                corrective action plan; or
                            (ii) has received any written communication 
                        by the Secretary regarding potential 
                        noncompliance with such hospital price 
                        transparency rule; and
                    (B) each hospital that is in compliance with 
                respect to such hospital price transparency rule and 
                has not received any written communication described in 
                paragraph (1)(B).
            (2) Foia requests.--Any penalty, notice, request, or other 
        communication described in subsection (a) shall be subject to 
        public disclosure, in full and without redaction, under section 
        552 of title 21, United States Code, notwithstanding any 
        exemptions or exclusions otherwise available under such section 
        552.
            (3) Reports to congress.--Not later than 1 year after the 
        date of enactment of this Act and each year thereafter, the 
        Secretary of Health and Human Services shall submit to 
        Congress, and make publicly available, a report that contains 
        information regarding complaints of alleged violations of law 
        and enforcement activities by the Secretary under the hospital 
        price transparency rule implementing section 2718(e) of the 
        Public Health Service Act (42 U.S.C. 300gg-18(e)). Such report 
        shall be made available to the public on the website of the 
        Centers for Medicare & Medicaid Services. Each such report 
        shall include, with respect to the year involved--
                    (A) the number of compliance and enforcement 
                inquiries opened by the Secretary pursuant to such 
                section;
                    (B) the number of notices of noncompliance issued 
                by the Secretary based on such inquiries;
                    (C) the identity of each hospital entity that 
                received a notice of noncompliance and the nature of 
                the failure giving rise to the Secretary's 
                determination of noncompliance;
                    (D) the amount of civil monetary penalty assessed 
                against the hospital entity;
                    (E) whether the hospital entity subsequently 
                corrected the noncompliance; and
                    (F) an analysis of factors contributing to 
                increasing health care costs.
            (4) Gao report.--Not later than 1 year after the date of 
        enactment of this Act, the Comptroller General of the United 
        States shall submit to the Committee on Energy and Commerce of 
        the House of Representatives and the Committee on Health, 
        Education, Labor, and Pensions and the Committee on Finance of 
        the Senate a report on the compliance and enforcement with the 
        hospital price transparency rule implementing section 2718(e) 
        of the Public Health Service Act (42 U.S.C. 300gg-18(e)). The 
        report shall include recommendations related to--
                    (A) improving price transparency to patients, 
                employers, and the public; and
                    (B) increased civil monetary penalty amounts to 
                ensure compliance.
            (5) Request for information.--Not later than January 1, 
        2025, the Secretary of Health and Human Services shall issue a 
        public request for information as to the best method through 
        which hospitals may be required to publish quality data (such 
        as data required to be reported under the Medicare Hospital 
        Compare program) alongside data required to be reported under 
        section 2718(e) of the Public Health Service Act (42 U.S.C. 
        300gg-18(e)).

SEC. 3. STRENGTHENING HEALTH INSURANCE TRANSPARENCY REQUIREMENTS.

    (a) Cost Sharing Transparency.--Section 1311(e)(3)(C) of the 
Patient Protection and Affordable Care Act (42 U.S.C. 18031(e)(3)(C)) 
is amended--
            (1) by striking ``The Exchange'' and inserting the 
        following:
                            ``(i) In general.--The Exchange'';
            (2) in clause (i), as inserted by paragraph (1)--
                    (A) by striking ``participating provider'' and 
                inserting ``provider'';
                    (B) by inserting ``shall include the information 
                specified in clause (ii) and'' after ``such 
                information'';
                    (C) by striking ``an Internet website'' and 
                inserting ``a self-service tool that meets the 
                requirements of clause (iii)''; and
                    (D) by striking ``and such other'' and all that 
                follows through the period and inserting ``or, at the 
                option such individual, through a paper disclosure 
                (provided at no cost to such individual) that meets 
                such requirements as the Secretary may specify.''; and
            (3) by adding at the end the following new clauses:
                            ``(ii) Specified information.--For purposes 
                        of clause (i), the information specified in 
                        this clause is, with respect to an item or 
                        service for which benefits are available under 
                        a health plan furnished by a health care 
                        provider, the following:
                                    ``(I) If such provider is a 
                                participating provider with respect to 
                                such item or service, the in-network 
                                rate (as defined in subparagraph (F)) 
                                for such item or service.
                                    ``(II) If such provider is not 
                                described in subclause (I), the maximum 
                                amount the plan will recognize as 
                                payment for such item or service.
                                    ``(III) The amount of cost sharing 
                                (including deductibles, copayments, and 
                                coinsurance) that the individual will 
                                incur for such item or service (which, 
                                in the case such item or service is to 
                                be furnished by a provider described in 
                                subclause (II), shall be calculated 
                                using the maximum amount described in 
                                such subclause).
                                    ``(IV) The amount the individual 
                                has already accumulated with respect to 
                                any deductible or out of pocket maximum 
                                under the plan (broken down, in the 
                                case separate deductibles or maximums 
                                apply to separate individuals enrolled 
                                in the plan, by such separate 
                                deductibles or maximums, in addition to 
                                any cumulative deductible or maximum).
                                    ``(V) In the case such plan imposes 
                                any frequency or volume limitations 
                                with respect to such item or service 
                                (excluding medical necessity 
                                determinations), the amount that such 
                                individual has accrued towards such 
                                limitation with respect to such item or 
                                service.
                                    ``(VI) Any prior authorization, 
                                concurrent review, step therapy, fail 
                                first, or similar requirements 
                                applicable to coverage of such item or 
                                service under such plan.
                            ``(iii) Self-service tool.--For purposes of 
                        clause (i), a self-service tool established by 
                        a health plan meets the requirements of this 
                        clause if such tool--
                                    ``(I) is based on an Internet 
                                website;
                                    ``(II) provides for real-time 
                                responses to requests described in such 
                                clause;
                                    ``(III) is updated in a manner such 
                                that information provided through such 
                                tool is timely and accurate;
                                    ``(IV) allows such a request to be 
                                made with respect to an item or service 
                                furnished by--
                                            ``(aa) a specific provider 
                                        that is a participating 
                                        provider with respect to such 
                                        item or service;
                                            ``(bb) all providers that 
                                        are participating providers 
                                        with respect to such plan and 
                                        such item or service; or
                                            ``(cc) a provider that is 
                                        not described in item (bb); and
                                    ``(V) provides that such a request 
                                may be made with respect to an item or 
                                service through use of the billing code 
                                for such item or service or through use 
                                of a descriptive term for such item or 
                                service.
                        The Secretary may require such tool, as a 
                        condition of complying with subclause (V), to 
                        link multiple billing codes to a single 
                        descriptive term if the Secretary determines 
                        that the billing codes to be so linked 
                        correspond to items and services with no more 
                        than a de minimis difference in patient 
                        experience in receiving such items and services 
                        and cost sharing imposed under such plan for 
                        such items and services.''.
    (b) Disclosure of Additional Information.--Section 1311(e)(3) of 
the Patient Protection and Affordable Care Act (42 U.S.C. 18031(e)(3)) 
is amended by adding at the end the following new subparagraphs:
                    ``(E) Rate and payment information.--
                            ``(i) In general.--Not later than January 
                        1, 2024, and every 3 months thereafter, each 
                        health plan shall submit to the Exchange, the 
                        Secretary, the State insurance commissioner, 
                        and make available to the public, the rate and 
                        payment information described in clause (ii) in 
                        accordance with clause (iii).
                            ``(ii) Rate and payment information 
                        described.--For purposes of clause (i), the 
                        rate and payment information described in this 
                        clause is, with respect to a health plan, the 
                        following:
                                    ``(I) With respect to each item or 
                                service (other than a drug) for which 
                                benefits are available under such plan, 
                                the in-network rate in effect as of the 
                                date of the submission of such 
                                information with each provider 
                                (identified by national provider 
                                identifier) that is a participating 
                                provider with respect to such item or 
                                service, other than such a rate in 
                                effect with a provider that, during the 
                                1-year period ending on such date, 
                                submitted fewer than 10 claims for such 
                                item or service to such plan.
                                    ``(II) With respect to each drug 
                                (identified by national drug code) for 
                                which benefits are available under such 
                                plan, the average amount paid by such 
                                plan (net of rebates, discounts, and 
                                price concessions) for such drug 
                                dispensed or administered during the 
                                90-day period beginning 180 days before 
                                such date of submission to each 
                                provider that was a participating 
                                provider with respect to such drug, 
                                broken down by each such provider 
                                (identified by national provider 
                                identifier), other than such an amount 
                                paid to a provider that, during such 
                                period, submitted fewer than 20 claims 
                                for such drug to such plan.
                                    ``(III) With respect to each item 
                                or service for which benefits are 
                                available under such plan, the amount 
                                billed, and the amount recognized by 
                                the plan, for each such item or service 
                                furnished during the 1-year period 
                                ending on such date by a provider that 
                                was not a participating provider with 
                                respect to such item or service, broken 
                                down by each such provider (identified 
                                by national provider identifier), other 
                                than amounts billed by, and amounts 
                                recognized by a plan with respect to, a 
                                provider that, during such period, 
                                submitted fewer than 10 claims for such 
                                item or service to such plan.
                            ``(iii) Manner of submission.--Rate and 
                        payment information required to be submitted 
                        and made available under this subparagraph 
                        shall be so submitted and so made available in 
                        3 separate machine-readable files corresponding 
                        to the information described in each of 
                        subclauses (I) through (III) of clause (ii) 
                        that meet such requirements as specified by the 
                        Secretary through rulemaking. Such requirements 
                        shall ensure that such files are limited to an 
                        appropriate size, are made available in a 
                        widely-available format that allows for 
                        information contained in such files to be 
                        compared across health plans, and are 
                        accessible to individuals at no cost and 
                        without the need to establish a user account or 
                        provider other credentials.
                            ``(iv) User guide.--Each health plan shall 
                        make available to the public instructions 
                        written in plain language explaining how 
                        individuals may search for information 
                        described in clause (ii) in files submitted in 
                        accordance with clause (iii).
                    ``(F) Definitions.--In this paragraph:
                            ``(i) Participating provider.--The term 
                        `participating provider' has the meaning given 
                        such term in section 2799A-1(a)(3) of the 
                        Public Health Service Act.
                            ``(ii) In-network rate.--The term `in-
                        network rate' means, with respect to a health 
                        plan and an item or service furnished by a 
                        provider that is a participating provider with 
                        respect to such plan and item or service, the 
                        contracted rate in effect between such plan and 
                        such provider for such item or service.''.
    (c) Reports.--
            (1) Compliance.--Not later than January 1, 2025, the 
        Comptroller General of the United States shall submit to 
        Congress a report containing--
                    (A) an analysis of health plan compliance with the 
                amendments made by this section;
                    (B) an analysis of enforcement of such amendments 
                by the Secretaries of Health and Human Services, Labor, 
                and the Treasury;
                    (C) recommendations relating to improving such 
                enforcement; and
                    (D) recommendations relating to improving public 
                disclosure, and public awareness, of information 
                required to be made available by such plans pursuant to 
                such amendments.
            (2) Prices.--Not later than January 1, 2028, the 
        Comptroller General of the United States shall submit to 
        Congress a report containing an assessment of differences in 
        negotiated prices (and any trends in such prices) in the 
        private market between--
                    (A) rural and urban areas;
                    (B) the individual, small group, and large group 
                markets;
                    (C) consolidated and nonconsolidated health care 
                provider areas (as specified by the Secretary);
                    (D) nonprofit and for-profit hospitals;
                    (E) nonprofit and for-profit insurers; and
                    (F) insurers serving local or regional areas and 
                insurers serving multistate or national areas.
    (d) Effective Date.--The amendments made by subsection (a) shall 
apply beginning January 1, 2024.
                                 &lt;all&gt;
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