I 
118TH CONGRESS 
1ST SESSION 
H. R. 410 
To amend the Public Health Service Act to provide for hospital and insurer 
price transparency. 
IN THE HOUSE OF REPRESENTATIVES 
JANUARY 20, 2023 
Mr. DAVIDSON introduced the following bill; which was referred to the 
Committee on Energy and Commerce 
A BILL 
To amend the Public Health Service Act to provide for 
hospital and insurer 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 Care Prices 
Revealed and Information to Consumers Explained Trans-
parency Act’’ or the ‘‘Health Care PRICE Transparency 
Act’’. 
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SEC. 2. PRICE TRANSPARENCY REQUIREMENTS. 
(a) HOSPITALS.—Section 2718(e) of the Public 
Health Service Act (42 U.S.C. 300gg–18(e)) is amend-
ed— 
(1) by striking ‘‘Each hospital’’ and inserting 
the following: 
‘‘(1) IN GENERAL.—Each hospital’’; 
(2) by inserting ‘‘, in plain language without 
subscription and free of charge, in a consumer- 
friendly, machine-readable format,’’ after ‘‘a list’’; 
and 
(3) by adding at the end the following: ‘‘Each 
hospital shall include in its list of standard charges, 
along with such additional information as the Sec-
retary may require with respect to such charges for 
purposes of promoting public awareness of hospital 
pricing in advance of receiving a hospital item or 
service, as applicable, the following: 
‘‘(A) A description of each item or service 
provided by the hospital. 
‘‘(B) The gross charge. 
‘‘(C) Any payer-specific negotiated charge 
clearly associated with the name of the third 
party payer and plan. 
‘‘(D) The de-identified minimum nego-
tiated charge. 
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‘‘(E) The de-identified maximum nego-
tiated charge. 
‘‘(F) The discounted cash price. 
‘‘(G) Any code used by the hospital for 
purposes of accounting or billing, including 
Current Procedural Terminology (CPT) code, 
the Healthcare Common Procedure Coding Sys-
tem (HCPCS) code, the Diagnosis Related 
Group (DRG), the National Drug Code (NDC), 
or other common payer identifier. 
‘‘(2) DELIVERY METHODS AND USE.— 
‘‘(A) IN
GENERAL.—Each hospital shall 
make public the standard charges described in 
paragraph (1) for as many of the 70 Centers 
for Medicaid & Medicare Services-specified 
shoppable services that are provided by the hos-
pital, and as many additional hospital-selected 
shoppable services as may be necessary for a 
combined total of at least 300 shoppable serv-
ices, including the rate at which a hospital pro-
vides and bills for that shoppable service. If a 
hospital does not provide 300 shoppable services 
in accordance with the previous sentence, the 
hospital shall make public the information spec-
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ified under paragraph (1) for as many 
shoppable services as it provides. 
‘‘(B) DETERMINATION
BY
CMS.—A hos-
pital shall be deemed by the Centers for Medi-
care & Medicaid Services to meet the require-
ments of subparagraph (A) if the hospital main-
tains an internet-based price estimator tool that 
meets the following requirements: 
‘‘(i) The tool provides estimates for as 
many of the 70 specified shoppable services 
that are provided by the hospital, and as 
many 
additional 
hospital-selected 
shoppable services as may be necessary for 
a combined total of at least 300 shoppable 
services. 
‘‘(ii) The tool allows health care con-
sumers to, at the time they use the tool, 
obtain an estimate of the amount they will 
be obligated to pay the hospital for the 
shoppable service. 
‘‘(iii) The tool is prominently dis-
played on the hospital’s website and easily 
accessible to the public, without subscrip-
tion, fee, or having to submit personal 
identifying information (PII), and search-
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able by service description, billing code, 
and payer. 
‘‘(3) DEFINITIONS.—Notwithstanding any other 
provision of law, for the purpose of paragraphs (1) 
and (2): 
‘‘(A) DE-IDENTIFIED
MAXIMUM
NEGO-
TIATED CHARGE.—The term ‘de-identified max-
imum negotiated charge’ means the highest 
charge that a hospital has negotiated with all 
third party payers for an item or service. 
‘‘(B) DE-IDENTIFIED
MINIMUM
NEGO-
TIATED CHARGE.—The term ‘de-identified min-
imum negotiated charge’ means the lowest 
charge that a hospital has negotiated with all 
third party payers for an item or service. 
‘‘(C) 
DISCOUNTED
CASH
PRICE.—The 
term ‘discounted cash price’ means the charge 
that applies to an individual who pays cash, or 
cash equivalent, for a hospital item or service. 
Hospitals that do not offer self-pay discounts 
may display the hospital’s undiscounted gross 
charges as found in the hospital chargemaster. 
‘‘(D) GROSS
CHARGE.—The term ‘gross 
charge’ means the charge for an individual item 
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or service that is reflected on a hospital’s 
chargemaster, absent any discounts. 
‘‘(E) 
PAYER-SPECIFIC
NEGOTIATED 
CHARGE.—The term ‘payer-specific negotiated 
charge’ means the charge that a hospital has 
negotiated with a third party payer for an item 
or service. 
‘‘(F) SHOPPABLE
SERVICE.—The term 
‘shoppable service’ means a service that can be 
scheduled by a health care consumer in ad-
vance. 
‘‘(G) STANDARD
CHARGES.—The term 
‘standard charges’ means the regular rate es-
tablished by the hospital for an item or service, 
including both individual items and services and 
service packages, provided to a specific group of 
paying patients, including the gross charge, the 
payer-specific negotiated charge, the discounted 
cash price, the de-identified minimum nego-
tiated charge, the de-identified maximum nego-
tiated charge, and other rates determined by 
the Secretary. 
‘‘(H) THIRD
PARTY
PAYER.—The term 
‘third party payer’ means an entity that is, by 
statute, contract, or agreement, legally respon-
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sible for payment of a claim for a health care 
item or service. 
‘‘(4) ENFORCEMENT.—In addition to any other 
enforcement actions or penalties that may apply 
under subsection (b)(3) or another provision of law, 
a hospital that fails to provide the information re-
quired by this subsection and has not completed a 
corrective action plan to comply with the require-
ments of such subsection shall be subject to a civil 
monetary penalty of an amount not to exceed $300 
per day that the violation is ongoing as determined 
by the Secretary. Such penalty shall be imposed and 
collected in the same manner as civil money pen-
alties under subsection (a) of section 1128A of the 
Social Security Act are imposed and collected.’’. 
(b) 
TRANSPARENCY
IN
COVERAGE.—Section 
1311(e)(3) of the Patient Protection and Affordable Care 
Act (42 U.S.C. 18031(e)(3)) is amended— 
(1) in subparagraph (A)— 
(A) by redesignating clause (ix) as clause 
(xii); and 
(B) by inserting after clause (viii), the fol-
lowing: 
‘‘(ix) In-network provider rates for 
covered items and services. 
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‘‘(x) Out-of-network allowed amounts 
and billed charges for covered items and 
services. 
‘‘(xi) Negotiated rates and historical 
net prices for covered prescription drugs.’’; 
(2) in subparagraph (B)— 
(A) in the heading, by striking ‘‘USE’’ and 
inserting ‘‘DELIVERY METHODS AND USE’’; 
(B) by inserting ‘‘and subparagraph (C)’’ 
after ‘‘subparagraph (A)’’; 
(C) by inserting ‘‘, as applicable,’’ after 
‘‘English proficiency’’; and 
(D) by inserting after the second sentence, 
the following: ‘‘The Secretary shall establish 
standards for the methods and formats for dis-
closing information to individuals. At a min-
imum, these standards shall include the fol-
lowing: 
‘‘(i) An internet-based self-service tool 
to provide information to an individual in 
plain language, without subscription and 
free of charge, in a machine readable for-
mat, through a self-service tool on an 
internet website that provides real-time re-
sponses based on cost-sharing information 
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which cost-sharing information for covered 
items and services is provided, and dis-
closes the applicable provider per-request 
limit to the individual, mailed to the indi-
vidual not later than 2 business days after 
receiving an individual’s request.’’; 
(3) in subparagraph (C)— 
(A) in the first sentence— 
(i) by striking ‘‘The Exchange’’ and 
inserting the following: 
‘‘(i) IN GENERAL.—The Exchange’’; 
(ii) by inserting ‘‘or out-of-network 
provider’’ after ‘‘item or service by a par-
ticipating provider’’; and 
(iii) by inserting before the period the 
following: ‘‘the following information: 
‘‘(i) An estimate of an individual’s 
cost-sharing liability for a requested cov-
ered item or service furnished by a pro-
vider, which shall reflect any cost-sharing 
reductions the individual would receive. 
‘‘(ii) A description of the accumulated 
amounts. 
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‘‘(iii) The in-network rate, including 
negotiated rates and underlying fee sched-
ule rates. 
‘‘(iv) 
The 
out-of-network 
allowed 
amount or any other rate that provides a 
more accurate estimate of an amount an 
issuer will pay, including the percent reim-
bursed by insurers to out-of-network pro-
viders, for the requested covered item or 
service furnished by an out-of-network pro-
vider. 
‘‘(v) A list of the items and services 
included in bundled payment arrangements 
for which cost-sharing information is being 
disclosed. 
‘‘(vi) A notification that coverage of a 
specific item or service is subject to a pre-
requisite, if applicable. 
‘‘(vii) A notice that includes the fol-
lowing information: 
‘‘(I) A statement that out-of-net-
work providers may bill individuals for 
the difference, including the balance 
billing, between a provider’s billed 
charges and the sum of the amount 
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collected from the insurer in the form 
of 
a 
copayment 
or 
coinsurance 
amount and the cost-sharing informa-
tion. 
‘‘(II) A statement that the actual 
charges for an individual’s covered 
item or service may be different from 
an estimate of cost-sharing liability 
depending on the actual items or serv-
ices the individual receives at the 
point of care. 
‘‘(III) A statement that the esti-
mate of cost-sharing liability for a 
covered item or service is not a guar-
antee that benefits will be provided 
for that item or service. 
‘‘(IV) A statement disclosing 
whether the plan counts copayment 
assistance and other third-party pay-
ments in the calculation of the indi-
vidual’s deductible and out-of-pocket 
maximum. 
‘‘(V) For items and services that 
are recommended preventive services 
under section 2713 of the Public 
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Health Service Act, a statement that 
an in-network item or service may not 
be subject to cost-sharing if it is billed 
as a preventive service in the insurer 
cannot determine whether the request 
is for a preventive or non-preventive 
item or service. 
‘‘(VI) Any additional informa-
tion, including other disclaimers, that 
the insurer determines is appropriate, 
provided the additional information 
does not conflict with the information 
required to be provided by this sub-
section.’’; 
(B) by striking the second sentence; and 
(C) by adding at the end the following: 
‘‘(ii) DEFINITIONS.—Notwithstanding 
any other provision of law, for the purpose 
of this subparagraph and subparagraphs 
(A) and (B): 
‘‘(I) ACCUMULATED AMOUNTS.— 
The 
term 
‘accumulated 
amounts’ 
means the amount of financial respon-
sibility an individual has incurred at 
the time a request for cost-sharing in-
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formation is made, with respect to a 
deductible or out-of-pocket limit, in-
cluding any expense that counts to-
ward a deductible or out-of-pocket 
limit, but exclude any expense that 
does not count toward a deductible or 
out-of-pocket limit. To the extent an 
insurer imposes a cumulative treat-
ment limitation on a particular cov-
ered item or service independent of in-
dividual medical necessity determina-
tions, the amount that has accrued to-
ward the limit on the item or service. 
‘‘(II) HISTORICAL NET PRICE.— 
The term ‘historical net price’ means 
the retrospective average amount an 
insurer paid for a prescription drug, 
inclusive of any reasonably allocated 
rebates, discounts, chargebacks, fees, 
and any additional price concessions 
received by the insurer with respect to 
the prescription drug. The allocation 
shall be determined by dollar value for 
non-product specific and product-spe-
cific rebates, discounts, chargebacks, 
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fees, and other price concessions to 
the extent that the total amount of 
any such price concession is known to 
the insurer at the time of publication 
of the historical net price. 
‘‘(III) NEGOTIATED RATE.—The 
term ‘negotiated rate’ means the 
amount a plan or issuer has contrac-
tually agreed to pay for a covered 
item or service, whether directly or in-
directly through a third party admin-
istrator or pharmacy benefit manager, 
to an in-network provider, including 
an in-network pharmacy or other pre-
scription drug dispenser, for covered 
items or services. 
‘‘(IV) 
OUT-OF-NETWORK
AL-
LOWED AMOUNT.—The term ‘out-of- 
network allowed amount’ means the 
maximum amount an insurer will pay 
for a covered item or service furnished 
by an out-of-network provider. 
‘‘(V) OUT-OF-NETWORK LIMIT.— 
The term ‘out-of-network limit’ means 
the maximum amount that an indi-
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vidual is required to pay during a cov-
erage period for his or her share of 
the costs of covered items and services 
under his or her plan or coverage, in-
cluding for self-only and other than 
self-only coverage, as applicable. 
‘‘(VI) UNDERLYING FEE SCHED-
ULE
RATES.—The term ‘underlying 
fee schedule rates’ means the rate for 
an item or service that a plan or 
issuer uses to determine a partici-
pant’s, 
beneficiary’s, 
or 
enrollee’s 
cost-sharing liability from a particular 
provider or providers, when the rate is 
different from the negotiated rate.’’; 
(4) in subparagraph (D), by striking ‘‘subpara-
graph (A)’’ and inserting ‘‘subparagraphs (A), (B), 
and (C)’’; and 
(5) by adding at the end the following: 
‘‘(F) APPLICATION
OF
PARAGRAPH.—In 
addition to qualified health plans (and plans 
seeking certification as qualified health plans), 
this paragraph (as amended by the Health Care 
Prices Revealed and Information to Consumers 
Explained Transparency Act) shall apply to 
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group health plans (including self-insured and 
fully insured plans) and health insurance cov-
erage (as such terms are defined in section 
2791 of the Public Health Service Act).’’. 
Æ 
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