119-hr267

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 267 Introduced in House

    (IH) ]

<DOC>

119th CONGRESS
 1st Session
 H. R. 267

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

_______________________________________________________________________

 IN THE HOUSE OF REPRESENTATIVES

 January 9, 2025

 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 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:
 ``
        (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 negotiated charge.
 ``
        (E) The de-identified maximum negotiated 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 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) '';
            (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 this 
 subparagraph and subparagraphs
        (A) and
        (B) :
 ``
            (I) Accumulated amounts.--The 
 term `accumulated amounts' means 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' 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-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' means 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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