Health Care PRICE Transparency Act
Bill: S.1524 | Sponsor: Sen. Braun, Mike (R-IN)
Policy area: Health

Summary:
Health Care Prices Revealed and Information to Consumers Explained Transparency Act or the Health Care PRICE Transparency Act  This bill provides statutory authority for requirements for hospitals and health insurance plans to disclose certain information about the costs for items and services.  Specifically, hospitals must publish in their list of standard charges certain rates negotiated with insurers, discounts for cash payments, and billing codes. Further, hospitals generally must publish the standard charges for the services provided by the hospital that may be scheduled in advance.  Additionally, insurance plans must publish the in-network and out-of-network charges for covered items and services and the negotiated prices for covered prescription drugs. Plans must provide a tool for consumers to search for this cost information. Consumers also may request additional information about the costs of specific items or services under their plans.

To amend the Public Health Service Act to provide for hospital and 
                      insurer price transparency.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Health Care Prices Revealed and 
Information to Consumers Explained Transparency Act'' or the ``Health 
Care PRICE Transparency Act''.

SEC. 2. PRICE TRANSPARENCY REQUIREMENTS.

    (a) Hospitals.--Section 2718(e) of the Public Health Service Act 
(42 U.S.C. 300gg-18(e)) is amended--
            (1) by striking ``Each hospital'' and inserting the 
        following:
            ``(1) In general.--Each hospital'';
            (2) by inserting ``, in plain language without subscription 
        and free of charge, in a consumer-friendly, machine-readable 
        format,'' after ``a list''; and
            (3) by adding at the end the following: ``Each hospital 
        shall include in its list of standard charges, along with such 
        additional information as the Secretary may require with 
        respect to such charges for purposes of promoting public 
        awareness of hospital pricing in advance of receiving a 
        hospital item or service, as applicable, the following:
                            ``(i) A description of each item or service 
                        provided by the hospital.
                            ``(ii) The gross charge.
                            ``(iii) Any payer-specific negotiated 
                        charge clearly associated with the name of the 
                        third party payer and plan.
                            ``(iv) The de-identified minimum negotiated 
                        charge.
                            ``(v) The de-identified maximum negotiated 
                        charge.
                            ``(vi) The discounted cash price.
                            ``(vii) Any code used by the hospital for 
                        purposes of accounting or billing, including 
                        Current Procedural Terminology (CPT) code, the 
                        Healthcare Common Procedure Coding System 
                        (HCPCS) code, the Diagnosis Related Group 
                        (DRG), the National Drug Code (NDC), or other 
                        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 hospital, and as many additional hospital-
                selected shoppable services as may be necessary for a 
                combined total of at least 300 shoppable services, 
                including the rate at which a hospital provides and 
                bills for that shoppable service. If a hospital does 
                not provide 300 shoppable services in accordance with 
                the previous sentence, the hospital shall make public 
                the information specified under paragraph (1) for as 
                many shoppable services as it provides.
                    ``(B) Determination by cms.--A hospital shall be 
                deemed by the Centers for Medicare & Medicaid Services 
                to meet the requirements of subparagraph (A) if the 
                hospital maintains an internet-based price estimator 
                tool that meets the following requirements:
                            ``(i) The tool provides estimates for as 
                        many of the 70 specified shoppable services 
                        that are provided by the hospital, and as many 
                        additional hospital-selected shoppable services 
                        as may be necessary for a combined total of at 
                        least 300 shoppable services.
                            ``(ii) The tool allows health care 
                        consumers to, at the time they use the tool, 
                        obtain an estimate of the amount they will be 
                        obligated to pay the hospital for the shoppable 
                        service.
                            ``(iii) The tool is prominently displayed 
                        on the hospital's website and easily accessible 
                        to the public, without subscription, fee, or 
                        having to submit personal identifying 
                        information (PII), and searchable by service 
                        description, billing code, and payer.
            ``(3) Definitions.--Notwithstanding any other provision of 
        law, for the purpose of paragraphs (1) and (2):
                    ``(A) De-identified maximum negotiated charge.--The 
                term `de-identified maximum negotiated charge' means 
                the highest charge that a hospital has negotiated with 
                all third party payers for an item or service.
                    ``(B) De-identified minimum negotiated charge.--The 
                term `de-identified minimum negotiated charge' means 
                the lowest charge that a hospital has negotiated with 
                all third party payers for an item or service.
                    ``(C) Discounted cash price.--The term `discounted 
                cash price' means the charge that applies to an 
                individual who pays cash, or cash equivalent, for a 
                hospital item or service. Hospitals that do not offer 
                self-pay discounts may display the hospital's 
                undiscounted gross charges as found in the hospital 
                chargemaster.
                    ``(D) Gross charge.--The term `gross charge' means 
                the charge for an individual item or service that is 
                reflected on a hospital's chargemaster, absent any 
                discounts.
                    ``(E) Payer-specific negotiated charge.--The term 
                `payer-specific negotiated charge' means the charge 
                that a hospital has negotiated with a third party payer 
                for an item or service.
                    ``(F) Shoppable service.--The term `shoppable 
                service' means a service that can be scheduled by a 
                health care consumer in advance.
                    ``(G) Standard charges.--The term `standard 
                charges' means the regular rate established by the 
                hospital for an item or service, including both 
                individual items and services and service packages, 
                provided to a specific group of paying patients, 
                including the gross charge, the payer-specific 
                negotiated charge, the discounted cash price, the de-
                identified minimum negotiated charge, the de-identified 
                maximum negotiated charge, and other rates determined 
                by the Secretary.
                    ``(H) Third party payer.--The term `third party 
                payer' means an entity that is, by statute, contract, 
                or agreement, legally responsible for payment of a 
                claim for a health care item or service.
            ``(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 required by this subsection and has not completed a 
        corrective action plan to comply with the requirements 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 penalties 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 
                following:
                            ``(ix) In-network provider rates for 
                        covered items and services.
                            ``(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)''; and
                    (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 disclosing information 
                to individuals. At a minimum, these standards shall 
                include the following:
                            ``(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 format, 
                        through a self-service tool on an internet 
                        website that provides real-time responses based 
                        on cost-sharing information that is accurate at 
                        the time of the request that allows, at a 
                        minimum, users to--
                                    ``(I) search for cost-sharing 
                                information for a covered item or 
                                service provided by a specific in-
                                network provider or by all in-network 
                                providers;
                                    ``(II) search for an out-of-network 
                                allowed amount, percentage of billed 
                                charges, or other rate that provides a 
                                reasonably accurate estimate of the 
                                amount an insurer will pay for a 
                                covered item or service provided by 
                                out-of-network providers; and
                                    ``(III) refine and reorder search 
                                results based on geographic proximity 
                                of in-network providers, and the amount 
                                of the individual's cost-sharing 
                                liability for the covered item or 
                                service, to the extent the search for 
                                cost-sharing information for covered 
                                items or services returns multiple 
                                results.
                            ``(ii) In paper form at the request of the 
                        individual that includes no fewer than 20 
                        providers per request with respect to which 
                        cost-sharing information for covered items and 
                        services is provided, and discloses the 
                        applicable provider per-request limit to the 
                        individual, mailed to the individual 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 
                        participating 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 covered item 
                        or service furnished by a provider, which shall 
                        reflect any cost-sharing reductions the 
                        individual would receive.
                            ``(ii) A description of the accumulated 
                        amounts.
                            ``(iii) The in-network rate, including 
                        negotiated rates and underlying fee schedule 
                        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 reimbursed by insurers to 
                        out-of-network providers, for the requested 
                        covered item or service furnished by an out-of-
                        network provider.
                            ``(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 
                        prerequisite, if applicable.
                            ``(vii) A notice that includes the 
                        following information:
                                    ``(I) A statement that out-of-
                                network providers may bill individuals 
                                for the difference, including the 
                                balance billing, between a provider's 
                                billed charges and the sum of the 
                                amount collected from the insurer in 
                                the form of a copayment or coinsurance 
                                amount and the cost-sharing 
                                information.
                                    ``(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 
                                services the individual receives at the 
                                point of care.
                                    ``(III) A statement that the 
                                estimate of cost-sharing liability for 
                                a covered item or service is not a 
                                guarantee that benefits will be 
                                provided for that item or service.
                                    ``(IV) A statement disclosing 
                                whether the plan counts copayment 
                                assistance and other third-party 
                                payments in the calculation of the 
                                individual's deductible and out-of-
                                pocket maximum.
                                    ``(V) For items and services that 
                                are recommended preventive services 
                                under section 2713 of the Public 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 information, 
                                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 
                                subsection.'';
                    (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 
                        subparagraphs (A), (B), and (C):
                                    ``(I) Accumulated amounts.--The 
                                term `accumulated amounts' mean the 
                                amount of financial responsibility an 
                                individual has incurred at the time a 
                                request for cost-sharing information is 
                                made, with respect to a deductible or 
                                out-of-pocket limit, including any 
                                expense that counts toward 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 treatment limitation on a 
                                particular covered item or service 
                                independent of individual medical 
                                necessity determinations, the amount 
                                that has accrued toward the limit on 
                                the item or service.
                                    ``(II) Historical net price.--The 
                                term `historical net price' mean 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-specific 
                                rebates, discounts, chargebacks, 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 contractually agreed 
                                to pay for a covered item or service, 
                                whether directly or indirectly through 
                                a third party administrator or pharmacy 
                                benefit manager, to an in-network 
                                provider, including an in-network 
                                pharmacy or other prescription drug 
                                dispenser, for covered items or 
                                services.
                                    ``(IV) Out-of-network allowed 
                                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 individual is 
                                required to pay during a coverage 
                                period for his or her share of the 
                                costs of covered items and services 
                                under his or her plan or coverage, 
                                including for self-only and other than 
                                self-only coverage, as applicable.
                                    ``(VI) Underlying fee schedule 
                                rates.--The term `underlying fee 
                                schedule rates' mean the rate for an 
                                item or service that a plan or issuer 
                                uses to determine a participant'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 ``subparagraph (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 
                group health plans (including self-insured and fully 
                insured plans) and health insurance coverage (as such 
                terms are defined in section 2791 of the Public Health 
                Service Act).''.
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