I 
118TH CONGRESS 
1ST SESSION H. R. 4822 
To improve price transparency with respect to certain health care services, 
and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JULY 24, 2023 
Mr. SMITH of Missouri introduced the following bill; which was referred to the 
Committee on Energy and Commerce, and in addition to the Committees 
on Ways and Means, Education and the Workforce, and the Budget, 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 improve price transparency with respect to certain health 
care services, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Health Care Price Transparency Act of 2023’’. 
(b) TABLE OF CONTENTS.—The table of contents for 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
TITLE I—HEALTH CARE PRICE TRANSPARENCY FOR PATIENTS 
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Sec. 101. Requiring certain facilities under the Medicare program to disclose 
certain information relating to charges and prices. 
Sec. 102. Promoting group health plan price transparency. 
Sec. 103. Oversight of pharmacy benefits manager services. 
Sec. 104. Reports on health care transparency tools and data requirements. 
Sec. 105. Report on integration in Medicare. 
TITLE II—FAIR PRICES FOR PATIENTS 
Sec. 201. Limitation on cost sharing to net price amount under Medicare part 
D. 
Sec. 202. Requiring a separate identification number and an attestation for 
each off-campus outpatient department of a provider. 
Sec. 203. Parity in Medicare payments for hospital outpatient department serv-
ices furnished off-campus. 
TITLE III—PATIENT-FOCUSED INVESTMENTS 
Sec. 301. Establishing requirements with respect to the use of prior authoriza-
tion under Medicare Advantage plans. 
Sec. 302. Extension of certain direct spending reductions. 
TITLE I—HEALTH CARE PRICE 
TRANSPARENCY FOR PATIENTS 
SEC. 101. REQUIRING CERTAIN FACILITIES UNDER THE 
MEDICARE PROGRAM TO DISCLOSE CERTAIN 
INFORMATION RELATING TO CHARGES AND 
PRICES. 
(a) IN GENERAL.—Part E of title XVIII of the Social 
Security Act (42 U.S.C. 1395x et seq.) is amended by add-
ing at the end the following new section: 
‘‘SEC. 1899C. HEALTH CARE PROVIDER PRICE TRANS-
PARENCY. 
‘‘(a) HOSPITAL PRICE TRANSPARENCY.— 
‘‘(1) IN
GENERAL.—Beginning January 1, 
2026, each specified hospital (as defined in para-
graph (6)) that receives payment under this title for 
furnishing items and services shall comply with the 
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price transparency requirement described in para-
graph (2). 
‘‘(2) REQUIREMENT DESCRIBED.— 
‘‘(A) IN GENERAL.—For purposes of para-
graph (1), the price transparency requirement 
described in this paragraph is, with respect to 
a specified hospital, that such hospital, in ac-
cordance with a method and format established 
by the Secretary under subparagraph (C), com-
pile and make public (without subscription and 
free of charge) for each year— 
‘‘(i) one or more lists, in a format 
specified by the Secretary (which may be a 
machine-readable format), of the hospital’s 
standard charges (including the informa-
tion described in subparagraph (B)) for 
each item and service furnished by such 
hospital; and 
‘‘(ii) information in a consumer- 
friendly format (as specified by the Sec-
retary)— 
‘‘(I) on the hospital’s prices (in-
cluding the information described in 
subparagraph (B)) for as many of the 
Centers for Medicare & Medicaid 
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Services-specified shoppable services 
that are furnished by the hospital, 
and as many additional hospital-se-
lected shoppable services (or all such 
additional services, if such hospital 
furnishes fewer than 300 shoppable 
services) as may be necessary for a 
combined total of at least 300 
shoppable services; and 
‘‘(II) that includes, with respect 
to each Centers for Medicare & Med-
icaid 
Services-specified 
shoppable 
service that is not furnished by the 
hospital, an indication that such serv-
ice is not so furnished. 
‘‘(B) INFORMATION DESCRIBED.—For pur-
poses of subparagraph (A), the information de-
scribed in this subparagraph is, with respect to 
standard charges and prices (as applicable) 
made public by a specified hospital, the fol-
lowing: 
‘‘(i) A description of each item or 
service, accompanied by, as applicable, the 
Healthcare Common Procedure Coding 
System code, the diagnosis-related group, 
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the national drug code, or other identifier 
used or approved by the Centers for Medi-
care & Medicaid Services. 
‘‘(ii) The gross charge, expressed as a 
dollar amount, for each such item or serv-
ice, when provided in, as applicable, the in-
patient setting and outpatient department 
setting. 
‘‘(iii) The discounted cash price, ex-
pressed as a dollar amount, for each such 
item or service when provided in, as appli-
cable, the inpatient setting and outpatient 
department setting (or, in the case no dis-
counted cash price is available for an item 
or service, the median price charged by the 
hospital for such item or service when pro-
vided in such settings for the previous 
three years, expressed as a dollar amount). 
‘‘(iv) Any other information the Sec-
retary may require for purposes of pro-
moting public awareness of specified hos-
pital standard charges or prices in advance 
of receiving an item or service from such 
a hospital, except information that is dupli-
cative of any other reporting requirement 
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under this section. Such information may 
include any current payer-specific nego-
tiated charges, clearly associated with the 
name of the third party payer and plan 
and expressed as a dollar amount, that 
apply to each such item or service when 
provided in, as applicable, the inpatient 
setting and outpatient department setting. 
‘‘(C) METHOD
AND
FORMAT.—Not later 
than January 1, 2026, the Secretary shall es-
tablish one or more methods and formats for 
specified facilities to use in compiling and mak-
ing public standard charges and prices (as ap-
plicable) pursuant to subparagraph (A). Any 
such method and format— 
‘‘(i) may be similar to any template 
made available by the Centers for Medicare 
& Medicaid Services as of the date of the 
enactment of this subparagraph; 
‘‘(ii) shall meet such standards as de-
termined appropriate by the Secretary in 
order to ensure the accessibility and 
usability of such charges and prices; and 
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‘‘(iii) shall be updated as determined 
appropriate by the Secretary, in consulta-
tion with stakeholders. 
‘‘(3) DEEMED COMPLIANCE WITH SHOPPABLE 
SERVICES
REQUIREMENT
FOR
HOSPITALS
WITH
A 
PRICE ESTIMATOR TOOL.— 
‘‘(A) IN GENERAL.—With respect to each 
year until the effective date of regulations im-
plementing the provisions of sections 2799A– 
1(f) and 2799B–6 of the Public Health Service 
Act (relating to advanced explanations of bene-
fits), including regulations on establishing data 
transfer standards to effectuate such provisions, 
a specified hospital shall be deemed to have 
complied with the requirement described in 
paragraph (2)(A)(ii)(I) (relating to shoppable 
services) if such hospital maintains a price esti-
mator tool described in subparagraph (B). 
‘‘(B) 
PRICE
ESTIMATOR
TOOL
DE-
SCRIBED.—For purposes of subparagraph (A), 
the price estimator tool described in this sub-
paragraph is, with respect to a specified hos-
pital, a tool that meets the following require-
ments: 
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‘‘(i) Such tool allows an individual to 
immediately obtain a price estimate (tak-
ing into account whether such individual is 
covered under any plan, coverage, or pro-
gram described in clause (iv)(III)) and the 
discounted cash price charged by a speci-
fied hospital, for each Centers for Medicare 
& Medicaid Services-specified shoppable 
service that is furnished by such hospital, 
and for each additional shoppable service 
as such hospital may select, such that price 
estimates are available through such tool 
for at least 300 shoppable services (or for 
all such services, if such hospital furnishes 
fewer than 300 shoppable services). 
‘‘(ii) Such tool allows an individual to 
obtain such an estimate by billing code and 
by service description. 
‘‘(iii) Such tool is prominently dis-
played on the public internet website of 
such hospital. 
‘‘(iv) Such tool does not require an in-
dividual seeking such an estimate to create 
an account or otherwise input personal in-
formation, except that such tool may re-
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quire that such individual provide informa-
tion specified by the Secretary, which may 
include the following: 
‘‘(I) The name of such individual. 
‘‘(II) The date of birth of such 
individual. 
‘‘(III) In the case such individual 
is covered under a group health plan, 
group or individual health insurance 
coverage, a Federal health care pro-
gram, or the program established 
under chapter 89 of title 5, United 
States Code, an identifying number 
assigned by such plan, coverage, or 
program to such individual. 
‘‘(IV) In the case of an individual 
described in subclause (III), an indi-
cation as to whether such individual is 
the primary insured individual under 
such plan, coverage, or program (and, 
if such individual is not the primary 
insured individual, a description of the 
individual’s relationship to such pri-
mary insured individual). 
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‘‘(V) Any other information spec-
ified by the Secretary. 
‘‘(v) Such tool contains a statement 
confirming the accuracy and completeness 
of information presented through such tool 
as of the date such request is made. 
‘‘(vi) Such tool meets any other re-
quirement specified by the Secretary. 
‘‘(4) MONITORING
COMPLIANCE.—The Sec-
retary shall, through notice and comment rule-
making and in consultation with the Inspector Gen-
eral of the Department of Health and Human Serv-
ices, establish a process to monitor compliance with 
this subsection. Such process shall ensure that each 
specified hospital’s compliance with this subsection 
is reviewed not less frequently than once every 3 
years. 
‘‘(5) ENFORCEMENT.— 
‘‘(A) IN GENERAL.—In the case of a speci-
fied hospital that fails to comply with the re-
quirements of 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 
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‘‘(ii) upon request of the Secretary, 
the hospital shall submit to the Secretary, 
not later than 45 days after the date of 
such request, 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 another provision of law, 
a specified hospital that has received a no-
tification under subparagraph (A)(i) and 
fails to comply with the requirements of 
this subsection by the date that is 90 days 
after such notification (or, in the case of 
such a hospital that has submitted a cor-
rective action plan described in subpara-
graph (A)(ii) in response to a request so 
described, by the date that is 90 days after 
the Secretary identifies the failure of such 
hospital to satisfactorily complete such cor-
rective action plan) shall be subject to a 
civil monetary penalty of an amount speci-
fied by the Secretary for each subsequent 
day during which such failure is ongoing. 
Such amount shall not exceed— 
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‘‘(I) in the case of a specified 
hospital that is a hospital or critical 
access hospital with 30 or fewer beds, 
$300 per day; and 
‘‘(II) in the case of any specified 
hospital and except as provided in 
clause (iii), $2,000,000 for a 1-year 
period. 
‘‘(ii) INCREASE
AUTHORITY.—In ap-
plying this subparagraph with respect to 
violations occurring in 2027 or a subse-
quent year, the Secretary may through no-
tice and comment rulemaking increase— 
‘‘(I) the limitation on the per day 
amount of any penalty applicable to a 
specified hospital that is a hospital or 
critical access hospital with 30 or 
fewer beds under clause (i)(I); 
‘‘(II) 
the 
limitation 
on 
the 
amount of any penalty applicable for 
a 1-year period under clause (i)(II); 
and 
‘‘(III) the limitation on the in-
crease of any penalty applied under 
clause (iii). 
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‘‘(iii) 
PERSISTENT
NONCOMPLI-
ANCE.—In the case of a specified hospital 
(other than a specified hospital that is a 
hospital or critical access hospital with 30 
or fewer beds) that the Secretary has de-
termined to be knowingly and willfully non-
compliant with the provisions of this sub-
section two or more times during a 1-year 
period, the Secretary may increase any 
penalty otherwise applicable under this 
subparagraph 
by 
not 
more 
than 
$1,000,000 and may require such hospital 
to complete such additional corrective ac-
tions plans as the Secretary may specify. 
‘‘(iv) APPLICATION OF CERTAIN PRO-
VISIONS.—The provisions of section 1128A 
(other than subsections (a) and (b) of such 
section) shall apply to a civil monetary 
penalty imposed under this subparagraph 
in the same manner as such provisions 
apply to a civil monetary penalty imposed 
under subsection (a) of such section. 
‘‘(v) AUTHORITY
TO
WAIVE
OR
RE-
DUCE
PENALTY.—The 
Secretary 
may 
waive or reduce any penalty otherwise ap-
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plicable with respect to a specified hospital 
under this subparagraph if the Secretary 
determines that imposition of such penalty 
would result in a significant hardship for 
such hospital (such as in the case of a hos-
pital located in a rural or underserved area 
where imposition of such penalty may re-
sult in, or contribute to, a lack of access 
to care for individuals in such area). 
‘‘(C) PUBLICATION
OF
HOSPITAL
PRICE 
TRANSPARENCY
INFORMATION.—Beginning on 
January 1, 2026, the Secretary shall make pub-
licly available on the public website of the Cen-
ters for Medicare & Medicaid Services informa-
tion with respect to compliance with the re-
quirements of this subsection and enforcement 
activities undertaken by the Secretary under 
this subsection. Such information shall be up-
dated not less than annually and include, with 
respect to each year— 
‘‘(i) the number of reviews of compli-
ance with this subsection undertaken by 
the Secretary; 
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‘‘(ii) the number of notifications de-
scribed in subparagraph (A)(i) sent by the 
Secretary; 
‘‘(iii) the identify of each specified 
hospital that was sent such a notification 
and a description of the nature of such 
hospital’s noncompliance with this sub-
section; 
‘‘(iv) the amount of any civil monetary 
penalty imposed on such hospital under 
subparagraph (B); 
‘‘(v) whether such hospital subse-
quently came into compliance with this 
subsection; and 
‘‘(vi) any other information as deter-
mined by the Secretary. 
‘‘(6) DEFINITIONS.—For purposes of this sub-
section: 
‘‘(A) 
DISCOUNTED
CASH
PRICE.—The 
term ‘discounted cash price’ means the charge 
that applies to an individual who pays cash, or 
cash equivalent, for a specified hospital-fur-
nished item or service. 
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‘‘(B) FEDERAL HEALTH CARE PROGRAM.— 
The term ‘Federal health care program’ has the 
meaning given such term in section 1128B. 
‘‘(C) GROSS
CHARGE.—The term ‘gross 
charge’ means the charge for an individual item 
or service that is reflected on a specified hos-
pital’s chargemaster, absent any discounts. 
‘‘(D) 
GROUP
HEALTH
PLAN; 
GROUP 
HEALTH
INSURANCE
COVERAGE; INDIVIDUAL 
HEALTH
INSURANCE
COVERAGE.—The terms 
‘group health plan’, ‘group health insurance 
coverage’, and ‘individual health insurance cov-
erage’ have the meaning given such terms in 
section 2791 of the Public Health Service Act. 
‘‘(E) 
PAYER-SPECIFIC
NEGOTIATED 
CHARGE.—The term ‘payer-specific negotiated 
charge’ means the charge that a specified hos-
pital 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 
and includes all ancillary items and services 
customarily furnished as part of such service. 
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‘‘(G) SPECIFIED
HOSPITAL.—The term 
‘specified hospital’ means a hospital (as defined 
in section 1861(e)), a critical access hospital (as 
defined in section 1861(mmm)(1)), or a rural 
emergency hospital (as defined in section 
1861(kkk)). 
‘‘(H) THIRD
PARTY
PAYER.—The term 
‘third party payer’ means an entity that is, by 
statute, contract, or agreement, legally respon-
sible for payment of a claim for a health care 
item or service. 
‘‘(b) 
AMBULATORY
SURGICAL
CENTER
PRICE 
TRANSPARENCY.— 
‘‘(1) IN
GENERAL.—Beginning January 1, 
2028, each ambulatory surgical center that receives 
payment under this title for furnishing items and 
services shall comply with the price transparency re-
quirement described in paragraph (2). 
‘‘(2) REQUIREMENT DESCRIBED.— 
‘‘(A) IN GENERAL.—For purposes of para-
graph (1), the price transparency requirement 
described in this subsection is, with respect to 
an ambulatory surgical center, that such sur-
gical center in accordance with a method and 
format established by the Secretary under sub-
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paragraph (C)), compile and make public (with-
out subscription and free of charge), for each 
year— 
‘‘(i) one or more lists, in a format 
specified by the Secretary, of the ambula-
tory surgical center’s standard charges (in-
cluding the information described in sub-
paragraph (B)) for each item and service 
furnished by such surgical center; 
‘‘(ii) information on the ambulatory 
surgical center’s prices (including the in-
formation described in subparagraph (B)) 
for as many of the Centers for Medicare & 
Medicaid Services-specified shoppable serv-
ices that are furnished by such surgical 
center, and as many additional ambulatory 
surgical center-selected shoppable services 
(or all such additional services, if such sur-
gical center furnishes fewer than 300 
shoppable services) as may be necessary 
for a combined total of at least 300 
shoppable services; 
‘‘(iii) with respect to each Centers for 
Medicare & Medicaid Services-specified 
shoppable service that is not furnished by 
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the ambulatory surgical center, an indica-
tion that such service is not so furnished; 
and 
‘‘(iv) any additional information speci-
fied by the Secretary. 
‘‘(B) INFORMATION DESCRIBED.—For pur-
poses of subparagraph (A), the information de-
scribed in this subparagraph is, with respect to 
standard charges and prices (as applicable) 
made public by an ambulatory surgical center, 
the following: 
‘‘(i) A description of each item or 
service, accompanied by, as applicable, the 
Healthcare Common Procedure Coding 
System code, the diagnosis-related group, 
the national drug code, or other identifier 
used or approved by the Centers for Medi-
care & Medicaid Services. 
‘‘(ii) The gross charge, expressed as a 
dollar amount, for each such item or serv-
ice. 
‘‘(iii) The discounted cash price, ex-
pressed as a dollar amount, for each such 
item or service (or, in the case no dis-
counted cash price is available for an item 
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or service, the gross charge for such item 
or service for the previous three years, ex-
pressed as a dollar amount). 
‘‘(iv) Any other information the Sec-
retary may require that is not duplicative 
of any other reporting requirement under 
this subsection for purposes of promoting 
public awareness of ambulatory surgical 
center prices in advance of receiving an 
item or service from such an ambulatory 
surgical center, which may include 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 
such item or service. 
‘‘(C) METHOD
AND
FORMAT.—Not later 
than January 1, 2028, the Secretary shall es-
tablish one or more methods and formats for 
ambulatory surgical centers to use in making 
public standard charges and prices (as applica-
ble) pursuant to subparagraph (A). Any such 
method and format— 
‘‘(i) may be similar to any template 
made available by the Centers for Medicare 
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& Medicaid Services as of the date of the 
enactment of this paragraph; 
‘‘(ii) shall meet such standards as de-
termined appropriate by the Secretary in 
order to ensure the accessibility and 
usability of such charges and prices; and 
‘‘(iii) shall be updated as determined 
appropriate by the Secretary, in consulta-
tion with stakeholders. 
‘‘(3) DEEMED COMPLIANCE WITH SHOPPABLE 
SERVICES
REQUIREMENT
FOR
AMBULATORY
SUR-
GICAL CENTERS WITH A PRICE ESTIMATOR TOOL.— 
‘‘(A) IN
GENERAL.—An ambulatory sur-
gical center shall be deemed to have complied 
with the requirement described in subsection 
(b)(2)(A) (relating to shoppable services) if 
such surgical center maintains a price estimator 
tool described in subparagraph (B). 
‘‘(B) 
PRICE
ESTIMATOR
TOOL
DE-
SCRIBED.—For purposes of subparagraph (A), 
the price estimator tool described in this sub-
paragraph is, with respect to an ambulatory 
surgical center, a tool that meets the following 
requirements: 
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‘‘(i) Such tool allows an individual to 
immediately obtain a price estimate (tak-
ing into account whether such individual is 
covered under any plan, coverage, or pro-
gram described in clause (iv)(III)) for each 
Centers for Medicare & Medicaid Services- 
specified shoppable service that is fur-
nished by such surgical center, and for 
each additional shoppable service as such 
surgical center may select, such that price 
estimates are available through such tool 
for at least 300 shoppable services (or for 
all such services, if such surgical center 
furnishes fewer than 300 shoppable serv-
ices). 
‘‘(ii) Such tool allows an individual to 
obtain such an estimate by billing code and 
by service description. 
‘‘(iii) Such tool is prominently dis-
played on the public internet website of 
such ambulatory surgical center. 
‘‘(iv) Such tool does not require an in-
dividual seeking such an estimate to create 
an account or otherwise input personal in-
formation, except that such tool may re-
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quire that such individual provide informa-
tion specified by the Secretary, which may 
include the following: 
‘‘(I) The name of such individual. 
‘‘(II) The date of birth of such 
individual. 
‘‘(III) In the case such individual 
is covered under a group health plan, 
group or individual health insurance 
coverage, a Federal health care pro-
gram, or the program established 
under chapter 89 of title 5, United 
States Code, an identifying number 
assigned by such plan, coverage, or 
program to such individual. 
‘‘(IV) In the case of an individual 
described in subclause (III), an indi-
cation as to whether such individual is 
the primary insured individual under 
such plan, coverage, or program (and, 
if such individual is not the primary 
insured individual, a description of the 
individual’s relationship to such pri-
mary insured individual). 
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‘‘(V) Any other information spec-
ified by the Secretary. 
‘‘(v) Such tool contains a statement 
confirming the accuracy and completeness 
of information presented through such tool 
as of the date such request is made. 
‘‘(vi) Such tool meets any other re-
quirement specified by the Secretary. 
‘‘(4) MONITORING
COMPLIANCE.—The Sec-
retary shall, through notice and comment rule-
making and in consultation with the Inspector Gen-
eral of the Department of Health and Human Serv-
ices, establish a process to monitor compliance with 
this subsection. Such process shall ensure that each 
ambulatory surgical center’s compliance with this 
subsection is reviewed not less frequently than once 
every 3 years. 
‘‘(5) ENFORCEMENT.— 
‘‘(A) IN GENERAL.—In the case of an am-
bulatory surgical center that fails to comply 
with the requirements of this subsection— 
‘‘(i) the Secretary shall notify such 
ambulatory surgical center of such failure 
not later than 30 days after the date on 
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which the Secretary determines such fail-
ure exists; and 
‘‘(ii) upon request of the Secretary, 
the ambulatory surgical center shall submit 
to the Secretary, not later than 45 days 
after the date of such request, a corrective 
action plan to comply with such require-
ments. 
‘‘(B) CIVIL MONETARY PENALTY.— 
‘‘(i) IN GENERAL.—In addition to any 
other enforcement actions or penalties that 
may apply under another provision of law, 
an ambulatory surgical center that has re-
ceived a notification under subparagraph 
(A)(i) and fails to comply with the require-
ments of this subsection by the date that 
is 90 days after such notification (or, in 
the case of an ambulatory surgical center 
that has submitted a corrective action plan 
described in subparagraph (A)(ii) in re-
sponse to a request so described, by the 
date that is 90 days after such submission) 
shall be subject to a civil monetary penalty 
of an amount specified by the Secretary for 
each subsequent day during which such 
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failure is ongoing (not to exceed $300 per 
day). 
‘‘(ii) INCREASE
AUTHORITY.—In ap-
plying this subparagraph with respect to 
violations occurring in 2027 or a subse-
quent year, the Secretary may through no-
tice and comment rulemaking increase the 
limitation on the per day amount of any 
penalty applicable to an ambulatory sur-
gical center under clause (i). 
‘‘(iii) APPLICATION OF CERTAIN PRO-
VISIONS.—The provisions of section 1128A 
(other than subsections (a) and (b) of such 
section) shall apply to a civil monetary 
penalty imposed under this subparagraph 
in the same manner as such provisions 
apply to a civil monetary penalty imposed 
under subsection (a) of such section. 
‘‘(iv) AUTHORITY TO WAIVE OR RE-
DUCE
PENALTY.—The 
Secretary 
may 
waive or reduce any penalty otherwise ap-
plicable with respect to an ambulatory sur-
gical center under this subparagraph if the 
Secretary determines that imposition of 
such penalty would result in a significant 
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hardship for such ambulatory surgical cen-
ter (such as in the case of an ambulatory 
surgical center located in a rural or under-
served area where imposition of such pen-
alty may result in, or contribute to, a lack 
of access to care for individuals in such 
area). 
‘‘(6) DEFINITIONS.—For purposes of this sec-
tion: 
‘‘(A) 
DISCOUNTED
CASH
PRICE.—The 
term ‘discounted cash price’ means the charge 
that applies to an individual who pays cash, or 
cash equivalent, for a item or service furnished 
by an ambulatory surgical center. 
‘‘(B) FEDERAL HEALTH CARE PROGRAM.— 
The term ‘Federal health care program’ has the 
meaning given such term in section 1128B. 
‘‘(C) GROSS
CHARGE.—The term ‘gross 
charge’ means the charge for an individual item 
or service that is reflected on a specified sur-
gical center’s chargemaster, absent any dis-
counts. 
‘‘(D) 
GROUP
HEALTH
PLAN; 
GROUP 
HEALTH
INSURANCE
COVERAGE; INDIVIDUAL 
HEALTH
INSURANCE
COVERAGE.—The terms 
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‘group health plan’, ‘group health insurance 
coverage’, and ‘individual health insurance cov-
erage’ have the meaning given such terms in 
section 2791 of the Public Health Service Act. 
‘‘(E) 
PAYER-SPECIFIC
NEGOTIATED 
CHARGE.—The term ‘payer-specific negotiated 
charge’ means the charge that a specified sur-
gical center 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 
and includes all ancillary items and services 
customarily furnished as part of such service. 
‘‘(G) THIRD
PARTY
PAYER.—The term 
‘third party payer’ means an entity that is, by 
statute, contract, or agreement, legally respon-
sible for payment of a claim for a health care 
item or service. 
‘‘(c) IMAGING SERVICES PRICE TRANSPARENCY.— 
‘‘(1) IN
GENERAL.—Beginning January 1, 
2025, each provider of services and supplier that re-
ceives payment under this title for furnishing a spec-
ified imaging service shall— 
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‘‘(A) make publicly available (in a form 
and manner specified by the Secretary) on an 
Internet website the information described in 
paragraph (2) with respect to each such service 
that such provider of services or supplier fur-
nishes; and 
‘‘(B) ensure that such information is up-
dated not less frequently than annually. 
‘‘(2) INFORMATION DESCRIBED.—For purposes 
of paragraph (1), the information described in this 
subsection is, with respect to a provider of services 
or supplier and a specified imaging service, the fol-
lowing: 
‘‘(A) The discounted cash price for such 
service (or, if no such price exists, the gross 
charge for such service). 
‘‘(B) If required by the Secretary, the 
deidentified minimum negotiated rate in effect 
between such provider or supplier and any 
group health plan or group or individual health 
insurance coverage for such service and the 
deidentified maximum negotiated rate in effect 
between such provider or supplier and any such 
plan or coverage for such service. 
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‘‘(3) METHOD AND FORMAT.—Not later than 
January 1, 2028, the Secretary shall establish one 
or more methods and formats for each provider of 
services and supplier to use in compiling and making 
public standard charges and prices (as applicable) 
pursuant to paragraph (1). Any such method and 
format— 
‘‘(A) may be similar to any template made 
available by the Centers for Medicare & Med-
icaid Services as of the date of the enactment 
of this subsection; 
‘‘(B) shall meet such standards as deter-
mined appropriate by the Secretary in order to 
ensure the accessibility and usability of such 
charges and prices; and 
‘‘(C) shall be updated as determined ap-
propriate by the Secretary, in consultation with 
stakeholders. 
‘‘(4) MONITORING
COMPLIANCE.—The Sec-
retary shall, through notice and comment rule-
making and in consultation with the Inspector Gen-
eral of the Department of Health and Human Serv-
ices, establish a process to monitor compliance with 
this subsection. 
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‘‘(5) SPECIFICATION OF SERVICES.—Not later 
than January 1, 2025, the Secretary shall publish a 
list of at least 50 imaging services that the Sec-
retary determines are shoppable (or all such services, 
if the Secretary determines that fewer than 50 such 
services are shoppable) between providers of services 
and suppliers of such services. The Secretary shall 
update such list as determined appropriate by the 
Secretary. 
‘‘(6) ENFORCEMENT.— 
‘‘(A) IN GENERAL.—In the case that the 
Secretary determines that a provider of services 
or supplier is not in compliance with paragraph 
(1)— 
‘‘(i) not later than 30 days after such 
determination, the Secretary shall notify 
such provider or supplier of such deter-
mination; 
‘‘(ii) upon request of the Secretary, 
such provider or supplier shall submit to 
the Secretary, not later than 45 days after 
the date of such request, a corrective ac-
tion plan to comply with such paragraph; 
and 
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‘‘(iii) if such provider or supplier con-
tinues to fail to comply with such para-
graph after the date that is 90 days after 
such notification is sent (or, in the case of 
such a provider or supplier that has sub-
mitted a corrective action plan described in 
clause (ii) in response to a request so de-
scribed, after the date that is 90 days after 
such submission), the Secretary may im-
pose a civil monetary penalty in an amount 
not to exceed $300 for each subsequent 
day during which such failure to comply or 
failure to submit is ongoing. 
‘‘(B) INCREASE AUTHORITY.—In applying 
this paragraph with respect to violations occur-
ring in 2027 or a subsequent year, the Sec-
retary may through notice and comment rule-
making increase the amount of the civil mone-
tary penalty under subparagraph (A)(iii). 
‘‘(C) APPLICATION
OF
CERTAIN
PROVI-
SIONS.—The provisions of section 1128A (other 
than subsections (a) and (b) of such section) 
shall apply to a civil monetary penalty imposed 
under this paragraph in the same manner as 
such provisions apply to a civil monetary pen-
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alty imposed under subsection (a) of such sec-
tion. 
‘‘(D) AUTHORITY TO WAIVE OR REDUCE 
PENALTY.—The Secretary may waive or reduce 
any penalty otherwise applicable with respect to 
a provider of services or supplier under this 
subparagraph if the Secretary determines that 
imposition of such penalty would result in a sig-
nificant hardship for such provider or supplier 
(such as in the case of a provider or supplier 
located in a rural or underserved area where 
imposition of such penalty may result in, or 
contribute to, a lack of access to care for indi-
viduals in such area). 
‘‘(E) CLARIFICATION
OF
NONAPPLICA-
BILITY
OF
OTHER
ENFORCEMENT
PROVI-
SIONS.—Notwithstanding any other provision of 
this title, this paragraph shall be the sole 
means of enforcing the provisions of this sub-
section. 
‘‘(7) DEFINITIONS.—In this subsection: 
‘‘(A) 
GROUP
HEALTH
PLAN; 
GROUP 
HEALTH
INSURANCE
COVERAGE; INDIVIDUAL 
HEALTH
INSURANCE
COVERAGE.—The terms 
‘group health plan’, ‘group health insurance 
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coverage’, and ‘individual health insurance cov-
erage’ have the meaning given such terms in 
section 2791 of the Public Health Service Act. 
‘‘(B) SPECIFIED
IMAGING
SERVICE.—the 
term ‘specified imaging service’ means an imag-
ing service that is included on the list published 
by the Secretary under subsection (e). 
‘‘(d) 
CLINICAL
LABORATORY
PRICE
TRANS-
PARENCY.— 
‘‘(1) IN
GENERAL.—Beginning January 1, 
2025, each applicable laboratory that receives pay-
ment under this title for furnishing a specified clin-
ical diagnostic laboratory test shall— 
‘‘(A) make publicly available (in a manner 
and form specified by the Secretary) on an 
Internet website the information described in 
paragraph (2) with respect to each such speci-
fied clinical diagnostic laboratory test that such 
laboratory is so available to furnish; and 
‘‘(B) ensure that such information is up-
dated not less frequently than annually. 
‘‘(2) INFORMATION DESCRIBED.—For purposes 
of paragraph (1), the information described in this 
subsection is, with respect to an applicable labora-
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tory and a specified clinical diagnostic laboratory 
test, the following: 
‘‘(A) The discounted cash price for such 
test (or, if no such price exists, the gross 
charge for such test). 
‘‘(B) If required by the Secretary, the 
deidentified minimum negotiated rate in effect 
between such laboratory and any group health 
plan or group or individual health insurance 
coverage for such test and the deidentified max-
imum negotiated rate in effect between such 
laboratory and any such plan or coverage for 
such test. 
‘‘(3) METHOD AND FORMAT.—Not later than 
January 1, 2028, the Secretary shall establish one 
or more methods and formats for each provider of 
services and supplier to use in compiling and making 
public standard charges and prices (as applicable) 
pursuant to paragraph (1). Any such method and 
format— 
‘‘(A) may be similar to any template made 
available by the Centers for Medicare & Med-
icaid Services as of the date of the enactment 
of this subsection; 
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‘‘(B) shall meet such standards as deter-
mined appropriate by the Secretary in order to 
ensure the accessibility and usability of such 
charges and prices; and 
‘‘(C) shall be updated as determined ap-
propriate by the Secretary, in consultation with 
stakeholders. 
‘‘(4) MONITORING
COMPLIANCE.—The Sec-
retary shall, through notice and comment rule-
making and in consultation with the Inspector Gen-
eral of the Department of Health and Human Serv-
ices, establish a process to monitor compliance with 
this subsection. 
‘‘(5) ENFORCEMENT.— 
‘‘(A) IN GENERAL.—In the case that the 
Secretary determines that an applicable labora-
tory is not in compliance with paragraph (1)— 
‘‘(i) not later than 30 days after such 
determination, the Secretary shall notify 
such laboratory of such determination; 
‘‘(ii) upon request of the Secretary, 
such laboratory shall submit to the Sec-
retary, not later than 45 days after such 
request is sent, a corrective action plan to 
comply with such subsection; and 
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‘‘(iii) if such laboratory continues to 
fail to comply with such paragraph after 
the date that is 90 days after such notifi-
cation is sent (or, in the case of such a 
laboratory that has submitted a corrective 
action plan described in clause(ii) in re-
sponse to a request so described, after the 
date that is 90 days after such submis-
sion), the Secretary may impose a civil 
monetary penalty in an amount not to ex-
ceed $300 for each subsequent day during 
which such failure to comply is ongoing. 
‘‘(B) INCREASE AUTHORITY.—In applying 
this paragraph with respect to violations occur-
ring in 2027 or a subsequent year, the Sec-
retary may through notice and comment rule-
making increase the amount of the civil mone-
tary penalty under subparagraph (A)(iii). 
‘‘(C) APPLICATION
OF
CERTAIN
PROVI-
SIONS.—The provisions of section 1128A (other 
than subsections (a) and (b) of such section) 
shall apply to a civil monetary penalty imposed 
under this paragraph in the same manner as 
such provisions apply to a civil monetary pen-
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alty imposed under subsection (a) of such sec-
tion. 
‘‘(D) AUTHORITY TO WAIVE OR REDUCE 
PENALTY.—The Secretary may waive or reduce 
any penalty otherwise applicable with respect to 
an applicable laboratory under this paragraph if 
the Secretary determines that imposition of 
such penalty would result in a significant hard-
ship for such laboratory (such as in the case of 
an applicable laboratory located in a rural or 
underserved area where imposition of such pen-
alty may result in, or contribute to, a lack of 
access to care for individuals in such area). 
‘‘(E) CLARIFICATION
OF
NONAPPLICA-
BILITY
OF
OTHER
ENFORCEMENT
PROVI-
SIONS.—Notwithstanding any other provision of 
this title, this subsection shall be the sole means 
of enforcing the provisions of this section. 
‘‘(6) DEFINITIONS.—In this subsection: 
‘‘(A) 
APPLICABLE
LABORATORY.—The 
term ‘applicable laboratory’ has the meaning 
given such term in section 414.502, of title 42, 
Code of Federal Regulations (or any successor 
regulation). 
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‘‘(B) 
GROUP
HEALTH
PLAN; 
GROUP 
HEALTH
INSURANCE
COVERAGE; INDIVIDUAL 
HEALTH
INSURANCE
COVERAGE.—The terms 
‘group health plan’, ‘group health insurance 
coverage’, and ‘individual health insurance cov-
erage’ have the meaning given such terms in 
section 2791 of the Public Health Service Act. 
‘‘(C) SPECIFIED
CLINICAL
DIAGNOSTIC 
LABORATORY TEST.—The term ‘specified clin-
ical diagnostic laboratory test’ means a clinical 
diagnostic laboratory test that is included on 
the list of shoppable services specified by the 
Centers for Medicare & Medicaid Services pur-
suant to section 180.60 of title 45, Code of 
Federal Regulations (or a successor regulation), 
other than such a test that is an advanced diag-
nostic laboratory test (as defined in section 
1834A(d)(5)).’’. 
(b) PUBLICATION OF HOSPITAL COMPLIANCE WITH 
PRICE TRANSPARENCY REQUIREMENTS.—Section 1886 of 
the Social Security Act (42 U.S.C. 1395ww) is amended 
by adding at the end the following new subsection: 
‘‘(u) PUBLICATION OF HOSPITAL COMPLIANCE WITH 
PRICE TRANSPARENCY REQUIREMENTS.— 
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‘‘(1) IN
GENERAL.—Beginning January 1, 
2026, the Secretary shall, for each hospital with re-
spect to which the Secretary has conducted a review 
of such hospital’s compliance with the provisions of 
section 1899C(a) and found such hospital non-
compliant with such provisions— 
‘‘(A) indicate such noncompliance on such 
hospital’s entry on the Hospital Compare inter-
net website (or a successor website); and 
‘‘(B) specify whether such hospital— 
‘‘(i) submitted a corrective action plan 
described in subsection (a)(5)(A)(ii) of 
such section (and, if so, the date such plan 
was received by the Secretary); or 
‘‘(ii) was subject to a civil monetary 
penalty 
imposed 
under 
subsection 
(a)(5)(B) of such section (and, if so, the 
date of the imposition of such penalty and 
the amount of such penalty). 
‘‘(2) ADDITIONS AND UPDATES.—The Secretary 
shall update any specification described in subpara-
graph (A) or (B) of paragraph (1) with respect to 
such hospital— 
‘‘(A) in the case of the specification de-
scribed in such paragraph (1)(A), as soon as 
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practicable after sending the notification de-
scribed in section 1899C(a)(5)(A)(i); and 
‘‘(B) in the case of the specification de-
scribed in such paragraph (1)(B)(ii), as soon as 
practicable after the imposition of a civil mone-
tary penalty described in such paragraph.’’. 
(c) CONFORMING AMENDMENT.—Section 2718(e) of 
the Public Health Service Act (42 U.S.C. 300gg–18(e)) 
is amended by adding at the end the following new sen-
tence: ‘‘The preceding sentence shall not apply beginning 
January 1, 2026.’’. 
(d) FUNDING.— 
(1) IN GENERAL.—In addition to funds other-
wise available, out of any moneys in the Treasury 
not otherwise appropriated, there are appropriated 
$10,000,000 for fiscal year 2024, to remain avail-
able until expended, for purposes of— 
(A) implementing the amendment made by 
this subsection (a); and 
(B) monitoring the compliance of entities 
with such amendment. 
(2) REPORT
ON
EXPENDITURES.—Not later 
than 5 years after the date of the enactment of this 
Act, the Secretary of Health and Human Services 
shall submit to the Committee on Ways and Means 
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and the Committee on Energy and Commerce of the 
House of Representatives and the Committee on Fi-
nance of the Senate a report that— 
(A) describes activities undertaken funded 
through funds made available under paragraph 
(1), including a specification of the amount of 
such funds expended for each such activity; and 
(B) identifies all entities with which the 
Secretary has entered into contracts for pur-
poses of implementing the amendment made by 
this subsection (a), monitoring compliance of 
entities with such amendment, or providing 
technical assistance to entities to promote com-
pliance with such amendment. 
(e) IMPLEMENTATION.— 
(1) ACCESSIBILITY.—In implementing section 
1899C(a)(2)(A)(ii) of the Social Security Act (as 
added by subsection (a)), the Secretary of Health 
and Human Services shall through rulemaking en-
sure that information made available pursuant to 
such amendment by an entity is so made available 
in plain, easily understandable language and that 
such entity provides access to such interpretation 
services, translations, and other assistive services to 
make such information accessible to individuals with 
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limited English proficiency and individuals with dis-
abilities. 
(2) TECHNICAL ASSISTANCE.—The Secretary of 
Health and Human Services shall, to the extent 
practicable, provide technical assistance to entities 
making public standard charges and prices (as appli-
cable) pursuant to the amendment made by sub-
section (a). 
SEC. 102. PROMOTING GROUP HEALTH PLAN PRICE TRANS-
PARENCY. 
(a) PRICE TRANSPARENCY REQUIREMENTS.— 
(1) IRC.— 
(A) IN GENERAL.—Section 9819 of the In-
ternal Revenue Code of 1986 (26. U.S.C. 9816) 
is amended to read as follows: 
‘‘SEC. 9819. PRICE TRANSPARENCY REQUIREMENTS. 
‘‘(a) COST SHARING TRANSPARENCY.— 
‘‘(1) IN GENERAL.—For plan years beginning 
on or after the date that is 2 years after the date 
of the enactment of the Health Care Price Trans-
parency Act of 2023, a group health plan shall per-
mit individuals to learn the amount of cost-sharing 
(including deductibles, copayments, and coinsurance) 
under the individual’s plan or coverage that the indi-
vidual would be responsible for paying with respect 
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to the furnishing of a specific item or service by a 
provider in a timely manner upon the request of the 
individual. At a minimum, such information shall in-
clude the information specified in paragraph (2) and 
shall be made available to such individual through a 
self-service tool that meets the requirements of para-
graph (3) or, at the option of such individual, 
through a paper disclosure or phone or other elec-
tronic disclosure (as selected by such individual and 
provided at no cost to such individual) that meets 
such requirements as the Secretary may specify. 
‘‘(2) SPECIFIED INFORMATION.—For purposes 
of paragraph (1), the information specified in this 
paragraph is, with respect to an item or service for 
which benefits are available under a group health 
plan furnished by a health care provider to a partici-
pant or beneficiary of such plan, the following: 
‘‘(A) If such provider is a participating 
provider with respect to such item or service, 
the in-network rate (as defined in subsection 
(c)) for such item or service. 
‘‘(B) If such provider is not described in 
subparagraph 
(A), 
the 
maximum 
allowed 
amount for such item or service. 
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ticipant or beneficiary has accrued towards such 
limitation with respect to such item or service. 
‘‘(F) Any prior authorization, concurrent 
review, step therapy, fail first, or similar re-
quirements applicable to coverage of such item 
or service under such plan. 
The Secretary may provide that information de-
scribed in any of subparagraphs (A) through (F) not 
be treated as information specified in this para-
graph, and specify additional information that shall 
be treated as information specified in this para-
graph, if determined appropriate by the Secretary. 
‘‘(3) SELF-SERVICE
TOOL.—For purposes of 
paragraph (1), a self-service tool established by a 
group health plan meets the requirements of this 
paragraph if such tool— 
‘‘(A) is based on an Internet website; 
‘‘(B) provides for real-time responses to re-
quests described in paragraph (1); 
‘‘(C) is updated in a manner such that in-
formation provided through such tool is timely 
and accurate at the time such request is made; 
‘‘(D) allows such a request to be made 
with respect to an item or service furnished 
by— 
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‘‘(i) a specific provider that is a par-
ticipating provider with respect to such 
item or service; 
‘‘(ii) all providers that are partici-
pating providers with respect to such item 
or service; or 
‘‘(iii) a provider that is not described 
in clause (ii); 
‘‘(E) 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; and 
‘‘(F) meets any other requirement deter-
mined appropriate by the Secretary. 
The Secretary may require such tool, as a condition 
of complying with subparagraph (E), to link multiple 
billing codes to a single descriptive term if the Sec-
retary determines that the billing codes to be so 
linked correspond to similar items and services. 
‘‘(b) RATE AND PAYMENT INFORMATION.— 
‘‘(1) IN GENERAL.—For plan years beginning 
on or after the date that is 2 years after the date 
of the enactment of the Health Care Price Trans-
parency Act of 2023, each group health plan (other 
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than a grandfathered health plan (as defined in sec-
tion 1251(e) of the Patient Protection and Afford-
able Care Act) shall, not less frequently than once 
every 3 months (or, in the case of information de-
scribed in paragraph (2)(B), not less frequently than 
monthly), make available to the public the rate and 
payment information described in paragraph (2) in 
accordance with paragraph (3). 
‘‘(2) RATE
AND
PAYMENT
INFORMATION
DE-
SCRIBED.—For purposes of paragraph (1), the rate 
and payment information described in this para-
graph is, with respect to a group health plan, the 
following: 
‘‘(A) With respect to each item or service 
(other than a drug) for which benefits are avail-
able under such plan, the in-network rate in ef-
fect with each provider 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 10 busi-
ness days before the date of the publication of 
such information, did not submit any claim for 
such item or service to such plan. 
‘‘(B) With respect to each drug (identified 
by national drug code) for which benefits are 
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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 begin-
ning 180 days before such date of publication 
to each provider that was a participating pro-
vider with respect to such drug, broken down by 
each such provider, other than such an amount 
paid to a provider that, during such period, 
submitted fewer than 20 claims for such drug 
to such plan. 
‘‘(C) With respect to each item or service 
for which benefits are available under such 
plan, the amount billed, and the amount al-
lowed by the plan, for each such item or service 
furnished during the 90-day period specified in 
subparagraph (B) by a provider that was not a 
participating provider with respect to such item 
or service, broken down by each such provider, 
other than items and services with respect to 
which fewer than 20 claims for such item or 
service were submitted to such plan during such 
period. 
‘‘(3) MANNER
OF
PUBLICATION.—Rate and 
payment information required to be made available 
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under this subsection shall be so made available in 
dollar amounts through 3 separate machine-readable 
files (or any successor technology, such as applica-
tion program interface technology, determined ap-
propriate by the Secretary) corresponding to the in-
formation described in each of subparagraphs (A) 
through (C) of paragraph (2) that meet such re-
quirements as specified by the Secretary. Such re-
quirements shall ensure that such files are limited to 
an appropriate size, do not include disclosure of un-
necessary duplicative information contained in other 
files made available under this subsection, are made 
available in a widely-available format through a pub-
licly-available website that allows for information 
contained in such files to be compared across group 
health plans, and are accessible to individuals at no 
cost and without the need to establish a user ac-
count or provide other credentials. 
‘‘(4) USER INSTRUCTIONS.—Each group health 
plan shall make available to the public instructions 
written in plain language explaining how individuals 
may search for information described in paragraph 
(2) in files submitted in accordance with paragraph 
(3). The Secretary shall develop and publish a tem-
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plate that such a plan may use in developing in-
structions for purposes of the preceding sentence. 
‘‘(5) ATTESTATION.—Each group health plan 
shall post, along with rate and payment information 
made public by such plan, an attestation that such 
information is complete and accurate. 
‘‘(c) DEFINITIONS.—In this section: 
‘‘(1) PARTICIPATING
PROVIDER.—The term 
‘participating provider’ has the meaning given such 
term in section 9816. 
‘‘(2) IN-NETWORK
RATE.—The term ‘in-net-
work 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 serv-
ice.’’. 
(B) CLERICAL AMENDMENT.—The item re-
lating to section 9819 of the table of sections 
for subchapter B of chapter 100 of the Internal 
Revenue Code of 1986 is amended to read as 
follows: 
‘‘Sec. 9819. Price transparency requirements.’’. 
(2) PHSA.—Section 2799A–4 of the Public 
Health Service Act (42 U.S.C. 300gg–114) is 
amended to read as follows: 
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‘‘SEC. 2799A–4. PRICE TRANSPARENCY REQUIREMENTS. 
‘‘(a) COST SHARING TRANSPARENCY.— 
‘‘(1) IN GENERAL.—For plan years beginning 
on or after the date that is 2 years after the date 
of the enactment of the Health Care Price Trans-
parency Act of 2023, a group health plan or a 
health insurance issuer offering group or individual 
health insurance coverage shall permit individuals to 
learn 
the 
amount 
of 
cost-sharing 
(including 
deductibles, copayments, and coinsurance) under the 
individual’s plan or coverage that the individual 
would be responsible for paying with respect to the 
furnishing of a specific item or service by a provider 
in a timely manner upon the request of the indi-
vidual. At a minimum, such information shall in-
clude the information specified in paragraph (2) and 
shall be made available to such individual through a 
self-service tool that meets the requirements of para-
graph (3) or, at the option of such individual, 
through a paper disclosure or phone or other elec-
tronic disclosure (as selected by such individual and 
provided at no cost to such individual) that meets 
such requirements as the Secretary may specify. 
‘‘(2) SPECIFIED INFORMATION.—For purposes 
of paragraph (1), the information specified in this 
paragraph is, with respect to an item or service for 
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which benefits are available under a group health 
plan or group or individual health insurance cov-
erage furnished by a health care provider to a par-
ticipant or beneficiary of such plan, or enrollee in 
such coverage, the following: 
‘‘(A) If such provider is a participating 
provider with respect to such item or service, 
the in-network rate (as defined in subsection 
(c)) for such item or service. 
‘‘(B) If such provider is not described in 
subparagraph 
(A), 
the 
maximum 
allowed 
amount for such item or service. 
‘‘(C) The estimated amount of cost sharing 
(including deductibles, copayments, and coin-
surance) that the participant or beneficiary will 
incur for such item or service (which, in the 
case such item or service is to be furnished by 
a provider described in subparagraph (B), shall 
be calculated using the maximum amount de-
scribed in such subparagraph). 
‘‘(D) The amount the participant, bene-
ficiary, or enrollee has already accumulated 
with respect to any deductible or out of pocket 
maximum, whether for items and services fur-
nished by a participating provider or for items 
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and services furnished by a provider that is not 
a participating provider, under the plan or cov-
erage (broken down, in the case separate 
deductibles or maximums apply to separate par-
ticipants, beneficiaries or enrollees enrolled in 
the plan or coverage, by such separate 
deductibles or maximums, in addition to any 
cumulative deductible or maximum). 
‘‘(E) In the case such plan or coverage im-
poses any frequency or volume limitations with 
respect to such item or service (excluding med-
ical necessity determinations), the amount that 
such participant, beneficiary, or enrollee has ac-
crued towards such limitation with respect to 
such item or service. 
‘‘(F) Any prior authorization, concurrent 
review, step therapy, fail first, or similar re-
quirements applicable to coverage of such item 
or service under such plan or coverage. 
The Secretary may provide that information de-
scribed in any of subparagraphs (A) through (F) not 
be treated as information specified in this para-
graph, and specify additional information that shall 
be treated as information specified in this para-
graph, if determined appropriate by the Secretary. 
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‘‘(3) SELF-SERVICE
TOOL.—For purposes of 
paragraph (1), a self-service tool established by a 
group health plan or group or individual health in-
surance coverage meets the requirements of this 
paragraph if such tool— 
‘‘(A) is based on an Internet website; 
‘‘(B) provides for real-time responses to re-
quests described in paragraph (1); 
‘‘(C) is updated in a manner such that in-
formation provided through such tool is timely 
and accurate at the time such request is made; 
‘‘(D) allows such a request to be made 
with respect to an item or service furnished 
by— 
‘‘(i) a specific provider that is a par-
ticipating provider with respect to such 
item or service; 
‘‘(ii) all providers that are partici-
pating providers with respect to such item 
or service; or 
‘‘(iii) a provider that is not described 
in clause (ii); 
‘‘(E) 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 
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or through use of a descriptive term for such 
item or service; and 
‘‘(F) meets any other requirement deter-
mined appropriate by the Secretary. 
The Secretary may require such tool, as a condition 
of complying with subparagraph (E), to link multiple 
billing codes to a single descriptive term if the Sec-
retary determines that the billing codes to be so 
linked correspond to similar items and services. 
‘‘(b) RATE AND PAYMENT INFORMATION.— 
‘‘(1) IN GENERAL.—For plan years beginning 
on or after the date that is 2 years after the date 
of the enactment of the Health Care Price Trans-
parency Act of 2023, each group health plan (other 
than a grandfathered health plan (as defined in sec-
tion 1251(e) of the Patient Protection and Afford-
able Care Act) or group or individual health insur-
ance coverage, shall, not less frequently than once 
every 3 months (or, in the case of information de-
scribed in paragraph (2)(B), not less frequently than 
monthly), make available to the public the rate and 
payment information described in paragraph (2) in 
accordance with paragraph (3). 
‘‘(2) RATE
AND
PAYMENT
INFORMATION
DE-
SCRIBED.—For purposes of paragraph (1), the rate 
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and payment information described in this para-
graph is, with respect to a group health plan or 
group or individual health insurance coverage, the 
following: 
‘‘(A) With respect to each item or service 
(other than a drug) for which benefits are avail-
able under such plan or coverage, the in-net-
work rate in effect with each provider 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 
10 business days before the date of the publica-
tion of such information, did not submit any 
claim for such item or service to such plan or 
coverage. 
‘‘(B) 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 or coverage (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 
publication to each provider that was a partici-
pating provider with respect to such drug, bro-
ken down by each such provider, other than 
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