I 
118TH CONGRESS 
1ST SESSION H. R. 4905 
To amend the Internal Revenue Code of 1986, the Public Health Service 
Act, and the Employee Retirement Income Security Act of 1974 to 
promote group health plan price transparency. 
IN THE HOUSE OF REPRESENTATIVES 
JULY 26, 2023 
Mr. FITZPATRICK (for himself and Ms. LEE of Nevada) introduced the fol-
lowing bill; which was referred to the Committee on Energy and Com-
merce, and in addition to the Committees on Education and the Work-
force, and Ways and Means, for a period to be subsequently determined 
by the Speaker, in each case for consideration of such provisions as fall 
within the jurisdiction of the committee concerned 
A BILL 
To amend the Internal Revenue Code of 1986, the Public 
Health Service Act, and the Employee Retirement In-
come Security Act of 1974 to promote group health 
plan price transparency. 
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 ‘‘Health Insurance Price 
Transparency Act of 2023’’. 
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SEC. 2. 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 this section, a group health plan 
shall permit individuals to learn the amount of cost- 
sharing (including deductibles, copayments, and co-
insurance) 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 individual. At a minimum, such infor-
mation shall include the information specified in 
paragraph (2) and shall be made available to such 
individual through a self-service tool that meets the 
requirements of paragraph (3) or, at the option of 
such individual, through a paper disclosure or phone 
or other electronic disclosure (as selected by such in-
dividual and provided at no cost to such individual) 
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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. 
‘‘(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 or bene-
ficiary has already accumulated with respect to 
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any deductible or out of pocket maximum, 
whether for items and services furnished by a 
participating provider or for items and services 
furnished by a provider that is not a partici-
pating provider, under the plan (broken down, 
in the case separate deductibles or maximums 
apply to separate participants and beneficiaries 
enrolled 
in 
the 
plan, 
by 
such 
separate 
deductibles or maximums, in addition to any 
cumulative deductible or maximum). 
‘‘(E) In the case such plan imposes any 
frequency or volume limitations with respect to 
such item or service (excluding medical neces-
sity determinations), the amount that such par-
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 
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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— 
‘‘(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 
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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 this section, each group health 
plan (other than a grandfathered health plan (as de-
fined in section 1251(e) of the Patient Protection 
and Affordable Care Act (42 U.S.C. 18011(e))) 
shall, not less frequently than once every 3 months 
(or, in the case of information described in para-
graph (2)(B), not less frequently than monthly), 
make available to the public the rate and payment 
information described in paragraph (2) in accord-
ance 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, 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 
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, 
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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 
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 
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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-
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 paragraph: 
‘‘(1) PARTICIPATING
PROVIDER.—The term 
‘participating provider’ has the meaning given such 
term in section 9816. 
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‘‘(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: 
‘‘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 this section, a group health plan 
or a health insurance issuer offering group or indi-
vidual health insurance coverage shall permit indi-
viduals to learn the amount of cost-sharing (includ-
ing deductibles, copayments, and coinsurance) under 
the individual’s plan or coverage that the individual 
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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 
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. 
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‘‘(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 
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). 
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‘‘(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. 
‘‘(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); 
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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 this section, each group health 
plan (other than a grandfathered health plan (as de-
fined in section 1251(e) of the Patient Protection 
and Affordable Care Act (42 U.S.C. 18011(e))) or 
group or individual health insurance coverage, shall, 
not less frequently than once every 3 months (or, in 
the case of information described in paragraph 
(2)(B), not less frequently than monthly), make 
available to the public the rate and payment infor-
mation 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 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-
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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 
such an amount paid to a provider that, during 
such period, submitted fewer than 20 claims for 
such drug to such plan or coverage. 
‘‘(C) With respect to each item or service 
for which benefits are available under such plan 
or coverage, the amount billed, and the amount 
allowed by the plan or coverage, for each such 
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item or service furnished during the 90-day pe-
riod specified in subparagraph (B) by a pro-
vider that was not a participating provider with 
respect to such item or service, broken down by 
each such provider, other than items and serv-
ices with respect to which fewer than 20 claims 
for such item or service were submitted to such 
plan or coverage during such period. 
‘‘(3) MANNER
OF
PUBLICATION.—Rate and 
payment information required to be made available 
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 
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health plans and group and individual health insur-
ance coverage, 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 and group or individual health insurance cov-
erage 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-
plate that such a plan or coverage may use in devel-
oping instructions for purposes of the preceding sen-
tence. 
‘‘(5) ATTESTATION.—Each group health plan 
and group or individual health insurance coverage 
shall post, along with rate and payment information 
made public by such plan or coverage, an attestation 
that such information is complete and accurate. 
‘‘(c) DEFINITIONS.—In this paragraph: 
‘‘(1) PARTICIPATING
PROVIDER.—The term 
‘participating provider’ has the meaning given such 
term in section 2791A–1(a)(3)(G)(ii). 
‘‘(2) IN-NETWORK
RATE.—The term ‘in-net-
work rate’ means, with respect to a health plan or 
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coverage and an item or service furnished by a pro-
vider that is a participating provider with respect to 
such plan and item or service, the contracted rate in 
effect between such plan or coverage and such pro-
vider for such item or service.’’. 
(3) ERISA.— 
(A) IN GENERAL.—Section 719 of the Em-
ployee Retirement Income Security Act of 1974 
(29 U.S.C. 1185h) is amended to read as fol-
lows: 
‘‘SEC. 719. 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 this section, a group health plan 
or a health insurance issuer offering group 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 re-
sponsible 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 individual. At a 
minimum, such information shall include the infor-
mation specified in paragraph (2) and shall be made 
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