I 
111TH CONGRESS 
2D SESSION 
H. R. 4803 
To ensure health care consumer and provider access to certain health benefits 
plan information and to amend title XIX of the Social Security Act 
to provide transparency in hospital price and quality information. 
IN THE HOUSE OF REPRESENTATIVES 
MARCH 10, 2010 
Mr. BARTON of Texas (for himself, Mr. GENE GREEN of Texas, Mr. BUR-
GESS, and Mr. STUPAK) introduced the following bill; which was referred 
to the Committee on Energy and Commerce, and in addition to the Com-
mittees on Ways and Means and Oversight and Government Reform, for 
a period to be subsequently determined by the Speaker, in each case for 
consideration of such provisions as fall within the jurisdiction of the com-
mittee concerned 
A BILL 
To ensure health care consumer and provider access to cer-
tain health benefits plan information and to amend title 
XIX of the Social Security Act to provide transparency 
in hospital price and quality information. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Patients’ Right to 
Know Act’’. 
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SEC. 2. HEALTH BENEFITS PLAN INFORMATION TRANS-
PARENCY. 
(a) ENSURING CONSUMER AND PROVIDER ACCESS 
TO HEALTH BENEFITS PLAN INFORMATION.— 
(1) IN GENERAL.—Each entity offering a health 
benefits plan (as defined in subsection (d)) shall 
make available to enrollees and potential enrollees of 
such plan the following information: 
(A) The items and services that are in-
cluded as part of the coverage offered by such 
plan and the items and services that are not so 
included. 
(B) An explicit and clear list of limitations 
and restrictions in the health insurance cov-
erage offered, along with a description of such 
limitations and restrictions. 
(C) A description of the process available 
for appealing coverage decisions made by such 
plan. 
(D) The number of appeals related to cov-
erage decisions made during the previous cal-
endar year and the outcomes of such appeals. 
(E) The amount of cost-sharing (including 
premiums, deductibles, copayments, co-insur-
ance, maximum possible annual out-of-pocket 
expenditure, and maximum possible lifetime 
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out-of-pocket expenditure) required by such 
plan. 
(F) The number of participating providers 
according to medical specialty type. 
(G) The extent to which a particular 
health care provider accepts coverage provided 
by such plan and the extent to which such a 
provider participates in the provider network of 
such plan. 
(H) The percentage of total expenditures 
made by such plan during the previous calendar 
year that are attributable to administrative 
costs and an explanation of all the assumptions 
and factors used to calculate such percentage. 
(I) The plan terms and conditions, claims 
payment policies and practices, periodic finan-
cial disclosure, data on enrollment and disen-
rollment, data on the number of claims denials, 
data on rating practices, information on cost- 
sharing and payments with respect to in-net-
work and out-of-network coverage, and any 
other information determined by the Secretary 
of Health and Human Services to be beneficial 
to consumers or medical providers. 
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(J) Information the Secretary of Health 
and Human Services deems appropriate regard-
ing the amount of waste and fraud in the oper-
ations of such plan, efforts to address such 
waste and fraud, and the outcomes of such ef-
forts. 
The requirement under this paragraph (including 
subparagraph (H)) shall apply only to entities offer-
ing health benefits plans (as defined in subsection 
(d)). 
(2) OUT-OF-POCKET
COST-SHARING
TRANS-
PARENCY.— 
(A) IN
GENERAL.—An entity offering a 
health benefits plan shall disclose, upon request 
of an enrollee of such plan, the amount of out- 
of-pocket cost-sharing (including deductibles, 
copayments, and coinsurance) under such plan 
that the enrollee would be responsible for pay-
ing with respect to the furnishing of a specific 
item or service by a provider participating in 
such plan in a timely manner. At a minimum, 
such information shall be made available to the 
enrollee, upon request, prior to seeking care, 
and shall be provided in a manner that allows 
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such enrollee to compare providers based on 
such information. 
(B) HEALTH CARE QUALITY INFORMATION 
TO BE DISCLOSED.—In disclosing information 
described in subparagraph (A), an entity offer-
ing a health benefits plan shall, to the extent 
practicable and appropriate, associate such in-
formation with any available risk-adjusted qual-
ity data measures. The Secretary may specify 
that such measures include those that have 
been endorsed by the National Quality Forum. 
(3) ADVANCE NOTICE OF PLAN CHANGES.—An 
entity offering a health benefits plan shall not make 
a change to such plan without reasonable and timely 
advance notice of such change to enrollees of such 
plan. 
(4) CONTRACTING
REIMBURSEMENT
TRANS-
PARENCY.—An entity offering a health benefits plan 
shall disclose to each health care provider informa-
tion relating to the reimbursement arrangements be-
tween such plan and such provider. 
(b) ADMINISTRATIVE PROVISIONS AND INFORMATION 
DESIGN.— 
(1) TIMELY DISCLOSURE AND UPDATES; ADDI-
TIONAL INFORMATION DISCLOSURES.— 
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(A) TIMELY DISCLOSURE AND UPDATES.— 
Each entity offering a health benefits plan shall 
provide for timely access to information de-
scribed in subsection (a) and consistent with 
such subsection, including through an Internet 
website. Such information shall first be made 
available not later than 18 months after the 
date of the enactment of this Act. Such infor-
mation shall be updated as often as is deemed 
feasible by the Secretary of Health and Human 
Services, but not less than once a calendar 
quarter. 
(B) ADDITIONAL
INFORMATION
DISCLO-
SURES.—The Secretary may undertake rule-
making as necessary in order to ensure that ad-
ditional information, as specified by the Sec-
retary, is progressively made available by enti-
ties offering health benefits plans, in order to 
provide for the maximum feasible reporting of 
information to meet the needs of consumers and 
providers of health care in making determina-
tions with regard to health care items, insur-
ance, and services. In no case shall such addi-
tional information be required to be made avail-
able by any entity other than an entity offering 
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a health benefits plan (as defined in subsection 
(d)). 
(2) INFORMATION DESIGN.— 
(A) IN GENERAL.—Each entity offering a 
health benefits plan shall ensure that the infor-
mation described in paragraph (1) is made 
available in a manner that— 
(i) is in a format that is easily acces-
sible, useable, and understandable to en-
rollees and potential enrollees of the plan 
as well as health care providers as applica-
ble; 
(ii) uses language that the intended 
audience can readily understand and that 
is clean, concise, well-organized, and fol-
lows other best practices of language writ-
ing; and 
(iii) to the greatest extent feasible, 
permits an individual to search the infor-
mation by a user-defined geographic area, 
such as within a 50-mile radius of the 
user’s home address. 
(B) ENABLING CONSUMERS TO COMPARE 
INFORMATION.—The Secretary of Health and 
Human Services shall, by final rule issued not 
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later than 12 months after the date of the en-
actment of this Act, require entities offering 
health benefits plans to disclose the information 
described in subsection (a)(1) in such a format 
as to allow individuals to compare the coverage 
options available to them in as uniform a man-
ner as possible. 
(c) PENALTY.—The Secretary shall provide for a 
methodology to impose a penalty fee against each entity 
offering a health benefits plan that fails to substantially 
meet the requirements of subsections (a) and (b). Such 
methodology shall— 
(1) provide for an increased penalty amount in 
the case of such an entity that knowingly misrepre-
sents information required to be disclosed under 
subsection (a) or under regulations issued pursuant 
to subsection (b)(1)(B); 
(2) vary the amount of such fee based on the 
size of the entity involved and type of infraction. 
The provisions of section 1128A (other than subsections 
(a) and (b)) shall apply to a penalty fee imposed under 
this subsection in the same manner as such provisions 
apply to a penalty or proceeding under section 1128A(a). 
(d) ENTITY OFFERING A HEALTH BENEFITS PLAN 
DEFINED.—For the purposes of this section, the term 
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‘‘entity offering a health benefits plan’’ means a health 
insurance issuer with respect to the offering of health in-
surance coverage, including in the individual market and 
small and large group market (as such terms are defined 
in section 2791 of the Public Health Service Act); a plan 
sponsor with respect to the offering of a group health plan 
(as defined in such section 2791); and entities responsible 
for the administration of governmental health plans (in-
cluding the Centers for Medicare & Medicaid Services with 
respect to the Medicare program under title XVIII of the 
Social Security Act, State agencies responsible for admin-
istration of State plans under the Medicaid program under 
title XIX of such Act or State child assistance plans under 
the State Children’s Health Insurance Program under 
title XXI of such Act, and the Office of Personnel Man-
agement with respect to the Federal Employees Health 
Benefits Program under chapter 89 of title 5, United 
States Code). 
SEC. 3. HOSPITAL AND AMBULATORY SURGICAL CENTER 
PRICE AND QUALITY TRANSPARENCY. 
(a) IN GENERAL.—Section 1902(a) of the Social Se-
curity Act (42 U.S.C. 1396a(a)) is amended— 
(1) by striking ‘‘and’’ at the end of paragraph 
(72); 
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(2) by striking the period at the end of para-
graph (73) and inserting ‘‘; and’’; 
(3) by inserting after paragraph (73) the fol-
lowing new paragraph: 
‘‘(74) provide that the State will establish and 
maintain laws, in accordance with the requirements 
of section 1921A, to require disclosure of informa-
tion on hospital and ambulatory surgical center 
charges and quality, to make such information avail-
able to the public and the Secretary.’’; and 
(4) by inserting after section 1921 the following 
new section: 
‘‘SEC. 1921A. PRICE AND QUALITY TRANSPARENCY. 
‘‘(a) IN GENERAL.—The requirements referred to in 
section 1902(a)(74) are that the laws of a State must— 
‘‘(1) require reporting to a State (or its agent) 
by each hospital located therein, of information on— 
‘‘(A) the charges for inpatient and out-
patient services typically performed (as defined 
by the Secretary through notice and comment 
rulemaking) by such hospital; 
‘‘(B) the reimbursement amount under 
title XVIII and under the State plan under this 
title for such services; and 
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‘‘(C) if the hospital allows for or provides 
reduced charges for individuals based on finan-
cial need, the factors considered in making de-
terminations for reductions in charges, includ-
ing any formula for such determination and the 
contact information for the specific department 
of a hospital that responds to such inquiries; 
‘‘(2) provide for notice to individuals seeking or 
requiring such services of the availability of informa-
tion on charges described in paragraph (1); 
‘‘(3) provide for timely access to such informa-
tion, including at least through an Internet website, 
by individuals seeking or requiring such services; 
and 
‘‘(4) provide for timely access to information re-
garding the quality of care at each hospital made 
publicly available in accordance with section 501 of 
the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003, section 1139A, or sec-
tion 1139B. 
‘‘(b) APPLICATION TO AMBULATORY SURGICAL CEN-
TERS.—The requirements described in subsection (a) shall 
apply, to the greatest extent practicable, to ambulatory 
surgical centers in the same manner as such requirements 
apply to hospitals, except that in applying paragraph (4) 
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of such subsection, the references described in such para-
graph shall be deemed to be a reference to section 
1833(i)(7). 
‘‘(c) CONSULTATION WITH STAKEHOLDERS.—For 
purposes of carrying out this section, the Secretary shall 
consult with appropriate stakeholders through a formal 
process to obtain guidance prior to issuing any imple-
menting policies. 
‘‘(d) HOSPITAL DEFINED.—For the purposes of this 
section, the term ‘hospital’ means an institution that 
meets the requirements of paragraphs (1) and (7) of sec-
tion 1861(e) and includes an institution to which section 
1820(c) applies. 
‘‘(e) AMBULATORY SURGICAL CENTER DEFINED.— 
For purposes of this section, the term ‘ambulatory sur-
gical center’ means a center described in section 
1832(a)(2)(F)(i).’’ 
(b) EFFECTIVE DATE.— 
(1) IN GENERAL.—The amendments made by 
subsection (a) shall apply to State plans beginning 
not later than 2 years after the date of the enact-
ment of this Act. 
(2) EXISTING
PROGRAMS.—The Secretary of 
Health and Human Services shall establish a process 
by which a State with an existing program may cer-
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