119-s2355

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[S. 2355 Introduced in Senate

    (IS) ]

<DOC>

119th CONGRESS
 1st Session
 S. 2355

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

_______________________________________________________________________

 IN THE SENATE OF THE UNITED STATES

 July 17, 2025

Mr. Marshall (for himself, Mr. Hickenlooper, Mr. Grassley, Ms. Hassan, 
 Mr. Sheehy, and Ms. Ernst) introduced the following bill; which was 
 read twice and referred to the Committee on Health, Education, Labor, 
 and Pensions

_______________________________________________________________________

 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 ``Patients Deserve Price Tags Act''.

SEC. 2. STRENGTHENING HOSPITAL PRICE TRANSPARENCY REQUIREMENTS.

    (a) In General.--

Section 2718

    (e) of the Public Health Service Act 
(42 U.S.C. 300gg-18

    (e) ) is amended to read as follows:
 ``

    (e) Standard Hospital Charges.--
 ``

    (1) In general.--
 ``
        (A) Disclosure of standard charges.--Each 
 hospital shall, in accordance with a method and format 
 established by the Secretary under subparagraph
            (C) , on 
 a monthly basis compile and make public (without 
 subscription and free of charge)--
 ``
            (i) all of the hospital's standard 
 charges (including the information described in 
 subparagraph
        (B) ) for each item and service 
 furnished by such hospital; and
 ``
            (ii) hospital standard charge 
 information, including the information 
 described in subparagraph
        (B) , in a consumer-
 friendly format (as specified by the 
 Secretary), that includes--
 ``
            (I) as many of the Centers for 
 Medicare & Medicaid Services-specified 
 shoppable services that are furnished 
 by the hospital, and as many additional 
 hospital-selected 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 through December 31, 
 2026, after which the hospital's prices 
 shall include all shoppable services; 
 and
 ``
            (II) with respect to each Centers 
 for Medicare & Medicaid Services-
 specified shoppable service that is not 
 furnished by the hospital, an 
 indication that such service is not so 
 furnished.
 ``
        (B) Standard charges described.--For purposes of 
 subparagraph
        (A) , standard charges means:
 ``
            (i) A plain language description of each 
 item or service, accompanied by any applicable 
 billing codes, including modifiers, using 
 commonly recognized billing code sets, 
 including the Current Procedural Terminology 
 code, the Healthcare Common Procedure Coding 
 System code, the diagnosis-related group, the 
 National Drug Code, and other nationally 
 recognized identifier.
 ``
            (ii) The gross charge, expressed as a 
 dollar amount, for each such item or service, 
 when provided in, as applicable, the inpatient 
 setting and outpatient department setting.
 ``
            (iii) The discounted cash price expressed 
 as a dollar amount, for each such item or 
 service when provided in, as applicable, the 
 inpatient setting and outpatient department 
 setting (or, in the case no discounted cash 
 price is available for an item or service, the 
 minimum cash price accepted by the hospital 
 from self-pay individuals for such item or 
 service, expressed as a dollar amount, as well 
 as, with respect to prices made public pursuant 
 to subparagraph
        (A)
            (ii) , a link to a consumer-
 friendly document that clearly explains the 
 hospital's charity care policy). The hospital 
 shall accept the discounted cash price as 
 payment in full from any patient that chooses 
 to pay in cash without regard to the patient's 
 coverage.
 ``
            (iv) The payer-specific negotiated 
 charges, expressed as a dollar amount and 
 clearly associated with the name of the 
 applicable third party payer and name of each 
 plan, that apply to each such item or service 
 when provided in, as applicable, the inpatient 
 setting and outpatient department setting. If 
 the charges are based on an algorithm, 
 percentage of another amount, or other formula 
 or criteria, the hospital also shall disclose 
 such algorithm, percentage, formula, or 
 criteria as set forth in its contract and any 
 other terms, schedules, exhibits, data, or 
 other information referenced in any such 
 contract as shall be required to determine and 
 disclose the negotiated charge.
 ``
            (v) The de-identified maximum and minimum 
 negotiated charges for each such item or 
 service, expressed as a non-zero dollar amount.
 ``
            (vi) Any other additional information the 
 Secretary may require for the purpose of 
 improving the accuracy of, or enabling 
 consumers to easily understand and compare, 
 standard charges and prices for an item or 
 service, except information that is duplicative 
 of any other reporting requirement under this 
 subsection. In the case of standard charges and 
 prices for an item or service included as part 
 of a bundled, per diem, episodic, or other 
 similar arrangement, the information described 
 in this subparagraph shall be made available as 
 determined appropriate by the Secretary.
 ``
            (C) Uniform method and format.--Not later than 
 January 1, 2026, the Secretary shall establish a 
 standard, uniform method and format for hospitals to 
 use in compiling and making public standard charges 
 pursuant to subparagraph
        (A)
            (i) and a standard, uniform 
 method and format for such hospitals to use in 
 compiling and making public prices pursuant to 
 subparagraph
        (A)
            (ii) . Such methods and formats shall--
 ``
            (i) in the case of such method and format 
 for making public standard charges pursuant to 
 subparagraph
        (A)
            (i) , ensure that such charges 
 are made available in a machine-readable 
 spreadsheet format;
 ``
            (ii) meet such standards as determined 
 appropriate by the Secretary in order to ensure 
 the accessibility and usability of such charges 
 and prices; and
 ``
            (iii) be updated as determined 
 appropriate by the Secretary, in consultation 
 with stakeholders.
 ``

    (2) No deemed compliance.--The availability of a price 
 estimator tool shall not be considered to deem compliance with 
 or otherwise vitiate the requirements of paragraph

    (1)
        (A)
            (ii) or any other requirements of this section. Furthermore, the use 
 of an estimator tool shall not be used for purposes of 
 compliance with any provisions in this Section.
 ``

    (3) Monitoring compliance.--The Secretary shall, in 
 consultation with the Inspector General of the Department of 
 Health and Human Services, establish a process to monitor 
 compliance with this subsection. Such process shall ensure that 
 each hospital's compliance with this subsection is reviewed not 
 less frequently than once every year.
 ``

    (4) Attestation.--A senior official from each hospital 
 (the Chief Executive Officer, Chief Financial Officer, or an 
 official of equivalent seniority) shall attest to the accuracy 
 and completeness of the disclosures made in accordance with the 
 hospital price transparency requirements set forth in this 
 regulation. Such attestation shall be deemed to be material to 
 payment from the Federal Government to the hospital.
 ``

    (5) Enforcement.--
 ``
        (A) In general.--In the case of a hospital that 
 fails to comply with the requirements of this 
 subsection, not later than 30 days after the date on 
 which the Secretary determines such failure exists, the 
 Secretary shall submit to such hospital a notification 
 of such determination, which shall include a request 
 for 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 hospital that 
 has received a request for a corrective action 
 plan under subparagraph
        (A) and fails to comply 
 with the requirements of this subsection by the 
 date that is 45 days after such request is made 
 shall be subject to a civil monetary penalty of 
 an amount specified by the Secretary for each 
 day (beginning with the day on which the 
 Secretary first determined that such hospital 
 was not complying with such requirements) 
 during which such failure was ongoing. Such 
 amount shall not exceed--
 ``
            (I) in the case of a hospital 
 with 30 or fewer beds, $300 per day;
 ``
            (II) in the case of a hospital 
 with more than 30 beds but fewer than 
 101 beds, $12.50 per bed per day (or, 
 in the case of such a hospital that has 
 been noncompliant with such 
 requirements for a 1-year period or 
 longer, beginning with the first day 
 following such 1-year period, $15 per 
 bed per day);
 ``
            (III) in the case of a hospital 
 with more than 100 beds but fewer than 
 301 beds, $17.50 per bed per day (or, 
 in the case of such a hospital that has 
 been noncompliant with such 
 requirements for a 1-year period or 
 longer, beginning with the first day 
 following such 1-year period, $20 per 
 bed per day);
 ``
            (IV) in the case of a hospital 
 with more than 300 beds but fewer than 
 501 beds, $20 per bed per day (or, in 
 the case of such a hospital that has 
 been noncompliant with such 
 requirements for a 1-year period or 
 longer, beginning with the first day 
 following such 1-year period, $25 per 
 bed per day); and
 ``
            (V) in the case of a hospital 
 with more than 500 beds, $25 per bed 
 per day (or, in the case of such a 
 hospital that has been noncompliant 
 with such requirements for a 1-year 
 period or longer, beginning with the 
 first day following such 1-year period, 
 $35 per bed per day).
 ``
            (ii) Increase authority.--In applying 
 this subparagraph with respect to violations 
 occurring in 2027 or a subsequent year, the 
 Secretary may through notice and comment 
 rulemaking increase--
 ``
            (I) the limitation on the per day 
 amount of any penalty applicable to a 
 hospital under clause
            (i) 
            (I) ;
 ``
            (II) the limitations on the per 
 bed per day amount of any penalty 
 applicable under any of subclauses
            (II) through
            (V) of clause
            (i) ; and
 ``
            (III) the limitation on the 
 increase of any penalty applied under 
 clause
            (iii) pursuant to the amounts 
 specified in subclause
            (II) of such 
 clause.
 ``
            (iii) Persistent noncompliance.--
 ``
            (I) In general.--In the case of a 
 hospital that the Secretary has 
 determined to be knowingly and 
 willfully noncompliant with the 
 provisions of this subsection two or 
 more times during a 1-year period, the 
 Secretary may increase any penalty 
 otherwise applicable under this 
 subparagraph by the amount specified in 
 subclause
            (II) with respect to such 
 hospital and may require such hospital 
 to complete such additional corrective 
 actions plans as the Secretary may 
 specify.
 ``
            (II) Specified amount.--For 
 purposes of subclause
            (I) , the amount 
 specified in this subclause is, with 
 respect to a hospital--
 ``

    (aa) with more than 30 
 beds but fewer than 101 beds, 
 an amount that is not less than 
 $500,000 and not more than 
 $1,000,000;
 ``

    (bb) with more than 100 
 beds but fewer than 301 beds, 
 an amount that is greater than 
 $1,000,000 and not more than 
 $2,000,000;
 ``
            (cc) with more than 300 
 beds but fewer than 501 beds, 
 an amount that is greater than 
 $2,000,000 and not more than 
 $4,000,000; and
 ``
            (dd) with more than 500 
 beds, and amount that is not 
 less than $5,000,000 and not 
 more than $10,000,000.
 ``
            (iv) Provision of technical assistance.--
 The Secretary may, to the extent practicable, 
 provide technical assistance relating to 
 compliance with the provisions of this section 
 to hospitals requesting such assistance.
 ``
            (v) Application of certain provisions.--
 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.
 ``
            (C) No waiver.--The Secretary shall not grant or 
 extend any waiver, delay, tolling, or other mitigation 
 of a civil monetary penalty for violation of this 
 subsection.
 ``

    (6) === Definitions. ===
-For purposes of this subsection:
 ``
        (A) Discounted cash price.--The term `discounted 
 cash price' means the minimum charge, exclusive of any 
 hospital or third-party payer assistance, that the 
 hospital accepts from an individual who pays cash, or 
 cash equivalent, for a hospital-furnished item or 
 service, without regard to patient coverage, as payment 
 in full.
 ``
        (B) 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.
 ``
            (C) Hospital.--The term `hospital' means a 
 hospital (as defined in 

section 1861

    (e) of the Social 
 Security Act), a critical access hospital (as defined 
 in 

section 1861
            (mmm) (1) of the Social Security Act), or 
 a rural emergency hospital (as defined in 

section 1861

    (kkk) of the Social Security Act), together with 
 any parent, subsidiary, or other affiliated provider or 
 supplier of health care items and services without 
 regard to whether such parent, subsidiary, or other 
 affiliated provider or supplier operates under separate 
 licensure, certification, or designation.
 ``
            (D) 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.
 ``
        (E) 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.
 ``
        (F) 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.
 ``

    (7) Rulemaking.--The Secretary shall implement this 
 subsection through notice and comment rulemaking in accordance 
 with 

section 553 of title 5, United States Code.''.

    (b) Effective Date.--

    (1) In general.--The amendment made by subsection

    (a) shall 
 apply beginning January 1, 2026.

    (2) Continued applicability of rules for previous years.--
 Nothing in the amendment made by this section may be construed 
 as affecting the applicability of the regulations codified at 
 part 180 of title 45, Code of Federal Regulations, before 
 January 1, 2025.
            (c) Continued Applicability of State Law.--The provisions of this 
Act shall not supersede any provision of State law that establishes, 
implements, or continues in effect any requirement or prohibition 
related to health care price transparency, except to the extent that 
such requirement or prohibition prevents the application of a 
requirement or prohibition of this Act.

SEC. 3. INCREASING PRICE TRANSPARENCY OF CLINICAL DIAGNOSTIC LABORATORY 
 TESTS.

 

Section 2718 of the Public Health Service Act (42 U.S.C. 300gg-18) 
is amended by adding at the end the following:
 ``

    (f) Clinical Diagnostic Laboratory Price Transparency.--
 ``

    (1) In general.--Beginning July 1, 2027, an applicable 
 laboratory shall--
 ``
        (A) make publicly available on an internet 
 website the information described in paragraph

    (2) with 
 respect to each such specified clinical diagnostic 
 laboratory test that such laboratory so furnishes; and
 ``
        (B) ensure that such information is updated not 
 less frequently than monthly, if there have been any 
 changes to such information.
 ``

    (2) Information described.--For purposes of paragraph

    (1) , the information described in this paragraph is, with 
 respect to an applicable laboratory and a specified clinical 
 diagnostic laboratory test, the following:
 ``
        (A) A plain language description of each item or 
 service, accompanied by any applicable billing codes, 
 including modifiers, using commonly recognized billing 
 code sets, including the Current Procedural Terminology 
 code, the Healthcare Common Procedure Coding System 
 code, the diagnosis-related group, the National Drug 
 Code, and other nationally recognized identifier.
 ``
        (B) The gross charge expressed as a dollar 
 amount, for each such item or service.
 ``
            (C) The discounted cash price expressed as a 
 dollar amount, for each such item or service (or, in 
 the case no discounted cash price is available for an 
 item or service, the minimum cash price accepted by the 
 laboratory from self-pay individuals for such item or 
 service when provided in such settings for the previous 
 three years, expressed as a dollar amount, as well as, 
 with respect to prices made public pursuant to 
 subparagraph
        (A)
            (ii) , a link to a consumer-friendly 
 document that clearly explains the laboratory's charity 
 care policy). The laboratory shall accept the 
 discounted or minimum cash price as payment in full 
 from any patient that chooses to pay in cash without 
 regard to the patient's coverage.
 ``
            (D) The payer-specific negotiated charges, 
 expressed as a dollar amount and clearly associated 
 with the name of the applicable third party payer and 
 name of each plan, that apply to each such item or 
 service when provided in, as applicable, the inpatient 
 setting and outpatient department setting. If the 
 charges are based on an algorithm, percentage of 
 another amount, or other formula or criteria, the 
 clinical diagnostic laboratory also shall disclose such 
 algorithm, percentage, formula, or criteria as set 
 forth in its contract and any other terms, schedules, 
 exhibits, data, or other information referenced in any 
 such contract as shall be required to determine and 
 disclose the negotiated charge.
 ``
        (E) The de-identified maximum and minimum 
 negotiated charges for each such item or service, 
 expressed as a non-zero dollar amount.
 ``
        (F) Any other additional information the 
 Secretary may require for the purpose of improving the 
 accuracy of, or enabling consumers to easily understand 
 and compare, standard charges and prices for an item or 
 service, except information that is duplicative of any 
 other reporting requirement under this subsection. In 
 the case of standard charges and prices for an item or 
 service included as part of a bundled, per diem, 
 episodic, or other similar arrangement, the information 
 described in this subparagraph shall be made available 
 as determined appropriate by the Secretary.
 ``

    (3) Uniform method and format.--Not later than January 1, 
 2027, the Secretary shall establish a standard, uniform method 
 and format for applicable laboratories to use in compiling and 
 making public information pursuant to paragraph

    (1) . Such 
 method and format shall--
 ``
        (A) include a machine-readable spreadsheet format 
 containing the information described in paragraph

    (2) for all items and services furnished by each 
 laboratory;
 ``
        (B) meet such standards as determined appropriate 
 by the Secretary in order to ensure the accessibility 
 and usability of such information; and
 ``
            (C) be updated as determined appropriate by the 
 Secretary, in consultation with stakeholders.
 ``

    (4) Inclusion of ancillary services.--Any price or rate 
 for a specified clinical diagnostic laboratory test available 
 to be furnished by an applicable laboratory made publicly 
 available in accordance with paragraph

    (1) shall include the 
 price or rate for any ancillary item or service (including 
 specimen collection services, specimen transport, 
 centrifugation, aliquoting, labeling, requisition processing, 
 and standard result reporting services) that would customarily 
 and routinely be furnished by such laboratory as part of such 
 test, as specified by the Secretary.
 ``

    (5) Enforcement.--
 ``
        (A) In general.--In the case that the Secretary 
 determines that an applicable laboratory 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; and
 ``
            (ii) if such laboratory continues to fail 
 to comply with such paragraph after the date 
 that is 90 days after such notification is 
 sent, the Secretary may impose a civil monetary 
 penalty in an amount not to exceed $300 for 
 each day (beginning with the day on which the 
 Secretary first determined that such laboratory 
 was failing to comply with such paragraph) 
 during which such failure is ongoing.
 ``
        (B) Increase authority.--In applying this 
 paragraph with respect to violations occurring in 2028 
 or a subsequent year, the Secretary may through notice 
 and comment rulemaking increase the per day limitation 
 on civil monetary penalties under subparagraph
        (A)
            (ii) .
 ``
            (C) Application of certain provisions.--The 
 provisions of 

section 1128A of the Social Security Act 
 (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 penalty imposed under 
 subsection

    (a) of such section.
 ``

    (6) Provision of technical assistance.--The Secretary 
 shall, to the extent practicable, provide technical assistance 
 relating to compliance with the provisions of this subsection 
 to applicable laboratories requesting such assistance.
 ``

    (7) === Definitions. ===
-In this subsection:
 ``
        (A) Applicable laboratory.--The term `applicable 
 laboratory' means a `laboratory' as such term is 
 defined in 

section 493.2, of title 42, Code of Federal 
 Regulations (or a successor regulation), except that 
 such term does not include a laboratory with respect to 
 which standard charges and prices for specified 
 clinical diagnostic laboratory tests furnished by such 
 laboratory are made available by a hospital pursuant to 
 subsection

    (e) of this section.
 ``
        (B) Discounted cash price.--The term `discounted 
 cash price' means the charge that applies to an 
 individual who pays cash, or cash equivalent, for an 
 item or service.
 ``
            (C) Gross charge.--The term `gross charge' means 
 the charge for an individual item or service that is 
 reflected on an applicable laboratory's chargemaster, 
 absent any discounts.
 ``
            (D) Payer-specific negotiated charge.--The term 
 `payer-specific negotiated charge' means the charge 
 that an applicable laboratory has negotiated with a 
 third party payer for an item or service.
 ``
        (E) Specified clinical diagnostic laboratory 
 test.--The term `specified clinical 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 (as described in subsection

    (e) of this 
 section), other than such a test that is only available 
 to be furnished by a single provider of services or 
 supplier.
 ``
        (F) 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.
 ``

    (8) Rulemaking.--The Secretary shall implement this 
 subsection through notice and comment rulemaking in accordance 
 with 

section 553 of title 5, United States Code.''.

SEC. 4. IMAGING TRANSPARENCY.

 

Section 2718 of the Public Health Service Act (42 U.S.C. 300gg-18), 
as amended by 

section 3, is further amended by adding at the end the 
following:
 ``

    (g) Imaging Services Price Transparency.--
 ``

    (1) In general.--Beginning July 1, 2027, each provider of 
 services or supplier that furnishes a specified imaging 
 service, other than such a provider or supplier with respect to 
 which standard charges and prices for such services furnished 
 by such provider or supplier are made available by a hospital 
 pursuant to subsection

    (e) , shall--
 ``
        (A) make publicly available (in accordance with 
 paragraph

    (3) ) on an internet website the information 
 described in paragraph

    (2) with respect to each such 
 service that such provider of services or supplier 
 furnishes; and
 ``
        (B) ensure that such information is updated not 
 less frequently than annually.
 ``

    (2) Information described.--For purposes of paragraph

    (1) , the information described in this paragraph is, with 
 respect to a provider of services or supplier and a specified 
 imaging service, the following:
 ``
        (A) A plain language description of each item or 
 service, accompanied by any applicable billing codes, 
 including modifiers, using commonly recognized billing 
 code sets, including the Current Procedural Terminology 
 code, the Healthcare Common Procedure Coding System 
 code, the diagnosis-related group, the National Drug 
 Code, and other nationally recognized identifier.
 ``
        (B) The gross charge expressed as a dollar 
 amount, for each such item or service.
 ``
            (C) The discounted cash price expressed as a 
 dollar amount, for each such item or service (or, in 
 the case no discounted cash price is available for an 
 item or service, the minimum cash price accepted by the 
 provider of services or supplier from self-pay 
 individuals for such item or service when provided in 
 such settings for the previous three years, expressed 
 as a dollar amount, as well as, with respect to prices 
 made public pursuant to subparagraph
        (A)
            (ii) , a link to 
 a consumer-friendly document that clearly explains the 
 provider of services or supplier's charity care 
 policy). The provider of services or supplier shall 
 accept the discounted or minimum cash price as payment 
 in full from any patient that chooses to pay in cash 
 without regard to the patient's coverage.
 ``
            (D) The payer-specific negotiated charges, 
 expressed as a dollar amount and clearly associated 
 with the name of the applicable third party payer and 
 name of each plan, that apply to each such item or 
 service when provided in, as applicable, the inpatient 
 setting and outpatient department setting. If the 
 charges are based on an algorithm, percentage of 
 another amount, or other formula or criteria, the 
 provider or supplier also shall disclose such 
 algorithm, percentage, formula, or criteria as set 
 forth in its contract and any other terms, schedules, 
 exhibits, data, or other information referenced in any 
 such contract as shall be required to determine and 
 disclose the negotiated charge.
 ``
        (E) The de-identified maximum and minimum 
 negotiated charges for each such item or service, 
 expressed as a non-zero dollar amount.
 ``
        (F) Any other additional information the 
 Secretary may require for the purpose of improving the 
 accuracy of, or enabling consumers to easily understand 
 and compare, standard charges and prices for an item or 
 service, except information that is duplicative of any 
 other reporting requirement under this subsection. In 
 the case of standard charges and prices for an item or 
 service included as part of a bundled, per diem, 
 episodic, or other similar arrangement, the information 
 described in this subparagraph shall be made available 
 as determined appropriate by the Secretary.
 ``

    (3) Uniform method and format.--Not later than January 1, 
 2027, the Secretary shall establish a standard, uniform method 
 and format for providers of services and suppliers to use in 
 making public information described in paragraph

    (2) . Any such 
 method and format shall--
 ``
        (A) include a machine-readable spreadsheet format 
 containing the information described in paragraph

    (2) for all items and services furnished by each provider 
 of services and supplier described in paragraph

    (1) ;
 ``
        (B) meet such standards as determined appropriate 
 by the Secretary in order to ensure the accessibility 
 and usability of such information; and
 ``
            (C) be updated as determined appropriate by the 
 Secretary, in consultation with stakeholders.
 ``

    (4) Monitoring compliance.--The Secretary shall, through 
 notice and comment rulemaking and in consultation with the 
 Inspector General of the Department of Health and Human 
 Services, establish a process to monitor compliance with this 
 subsection.
 ``

    (5) 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 determination;
 ``
            (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 action plan 
 to comply with such paragraph; and
 ``
            (iii) if such provider or supplier 
 continues to fail to comply with such paragraph 
 after the date that is 90 days after such 
 notification is sent (or, in the case of such a 
 provider or supplier that has submitted a 
 corrective action plan described in clause
            (ii) in response to a request so described, after 
 the date that is 90 days after such 
 submission), the Secretary may impose a civil 
 monetary penalty in an amount not to exceed 
 $300 for each day (beginning with the day on 
 which the Secretary first determined that such 
 provider or supplier was failing to comply with 
 such paragraph) during which such failure to 
 comply or failure to submit is ongoing.
 ``
        (B) Increase authority.--In applying this 
 paragraph with respect to violations occurring in 2027 
 or a subsequent year, the Secretary may through notice 
 and comment rulemaking increase the amount of the civil 
 monetary penalty under subparagraph
        (A)
            (iii) .
 ``
            (C) Application of certain provisions.--The 
 provisions of 

section 1128A of the Social Security Act 
 (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 penalty imposed under 
 subsection

    (a) of such section.
 ``
            (D) No authority to waive or reduce penalty.--The 
 Secretary shall not grant or extend any waiver, delay, 
 tolling, or other mitigation of a civil monetary 
 penalty for violation of this subsection.
 ``
        (E) Provision of technical assistance.--The 
 Secretary shall, to the extent practicable, provide 
 technical assistance relating to compliance with the 
 provisions of this subsection to providers of services 
 and suppliers requesting such assistance.
 ``
        (F) Clarification of nonapplicability of other 
 enforcement provisions.--Notwithstanding any other 
 provision of this title, this paragraph shall be the 
 sole means of enforcing the provisions of this 
 subsection.
 ``

    (6) Specified imaging service defined.--the term 
 `specified imaging service' means an imaging service that is a 
 Centers for Medicare & Medicaid Services-specified shoppable 
 service (as described in subsection

    (e) ).
 ``

    (7) Rulemaking.--The Secretary shall implement this 
 subsection through notice and comment rulemaking in accordance 
 with 

section 553 of title 5, United States Code.''.

SEC. 5. AMBULATORY SURGICAL CENTER PRICE TRANSPARENCY REQUIREMENTS.

 

Section 2718 of the Public Health Service Act (42 U.S.C. 300gg-18), 
as amended by 

section 4, is further amended by adding at the end the 
following:
 ``

    (h) Ambulatory Surgery Center Transparency.--
 ``

    (1) In general.--Beginning July 1, 2027, each specified 
 ambulatory surgical center shall comply with the price 
 transparency requirement described in paragraph

    (2) .
 ``

    (2) Requirement described.--
 ``
        (A) In general.--A specified ambulatory surgical 
 center, in accordance with a method and format 
 established by the Secretary under subparagraph
            (C) , 
 shall compile and make public (without subscription and 
 free of charge), for each year--
 ``
            (i) one or more lists, in a machine-
 readable format specified by the Secretary, of 
 the ambulatory surgical center's standard 
 charges (including the information described in 
 subparagraph
        (B) ) for each item and service 
 furnished by such surgical center;
 ``
            (ii) information in a consumer-friendly 
 format (as specified by the Secretary) on the 
 ambulatory surgical center's prices (including 
 the information described in subparagraph
        (B) ) 
 for as many of the Centers for Medicare & 
 Medicaid Services-specified shoppable services 
 included on the list described in subsection

    (e) that are furnished by such surgical center, 
 and as many additional ambulatory surgical 
 center-selected shoppable services (or all such 
 additional services, if such surgical center 
 furnishes fewer than 300 shoppable services) as 
 may be necessary for a combined total of at 
 least 300 shoppable services; and
 ``
            (iii) with respect to each Centers for 
 Medicare & Medicaid Services-specified 
 shoppable service (as described in clause
            (ii) ) 
 that is not furnished by the ambulatory 
 surgical center, an indication that such 
 service is not so furnished.
 ``
        (B) Information described.--For purposes of 
 subparagraph
        (A) , the information described in this 
 subparagraph is, with respect to standard charges and 
 prices made public by a specified ambulatory surgical 
 center, the following:
 ``
            (i) A description of each item or 
 service, accompanied by the Healthcare Common 
 Procedure Coding System code, the national drug 
 code, or other identifier used or approved by 
 the Centers for Medicare & Medicaid Services.
 ``
            (ii) The gross charge, expressed as a 
 dollar amount, for each such item or service.
 ``
            (iii) The discounted cash price, 
 expressed as a dollar amount, for each such 
 item or service (or, in the case no discounted 
 cash price is available for an item or service, 
 the minimum cash price accepted by the 
 specified ambulatory surgical center from self-
 pay individuals for such item or service when 
 provided in such settings for the previous 
 three years, expressed as a dollar amount, as 
 well as, with respect to prices made public 
 pursuant to subparagraph
        (A)
            (ii) , a link to a 
 consumer-friendly document that clearly 
 explains the provider of services or supplier's 
 charity care policy). The specified ambulatory 
 surgical center shall accept the discounted 
 cash price as payment in full from any patient 
 that chooses to pay in cash without regard to 
 the patient's coverage.
 ``
            (iv) The payer-specific negotiated 
 charges, expressed as a dollar amount and 
 clearly associated with the name of the 
 applicable third party payer and name of each 
 plan, that apply to each such item or service 
 when provided in, as applicable, the inpatient 
 setting and outpatient department setting. If 
 the charges are based on an algorithm, 
 percentage of another amount, or other formula 
 or criteria, the ambulatory surgical center 
 also shall disclose such algorithm, percentage, 
 formula, or criteria as set forth in its 
 contract and any other terms, schedules, 
 exhibits, data, or other information referenced 
 in any such contract as shall be required to 
 determine and disclose the negotiated charge.
 ``
            (v) The de-identified maximum and minimum 
 negotiated charges for each such item or 
 service, expressed as a non-zero dollar amount.
 ``
            (vi) Any other additional information the 
 Secretary may require for the purpose of 
 improving the accuracy of, or enabling 
 consumers to easily understand and compare, 
 standard charges and prices for an item or 
 service, except information that is duplicative 
 of any other reporting requirement under this 
 subsection.
 ``
            (C) Uniform method and format.--Not later than 
 January 1, 2027, the Secretary shall establish a 
 standard, uniform method and format for specified 
 ambulatory surgical centers to use in making public 
 standard charges pursuant to subparagraph
        (A)
            (i) and a 
 standard, uniform method and format for such centers to 
 use in making public prices pursuant to subparagraph
        (A)
            (ii) . Any such method and format shall--
 ``
            (i) in the case of such charges made 
 public by an ambulatory surgical center, ensure 
 that such charges are made available in a 
 machine-readable format;
 ``
            (ii) meet such standards as determined 
 appropriate by the Secretary in order to ensure 
 the accessibility and usability of such charges 
 and prices; and
 ``
            (iii) be updated as determined 
 appropriate by the Secretary, in consultation 
 with stakeholders.
 ``

    (3) No deemed compliance.--The availability of a price 
 estimator tool shall not be considered to deem compliance with 
 or otherwise vitiate the requirements of this subsection

    (aa) . 
 Furthermore, the use of an estimator tool shall not be used for 
 purposes of compliance with any provisions in this subsection.
 ``

    (4) Monitoring compliance.--The Secretary shall, in 
 consultation with the Inspector General of the Department of 
 Health and Human Services, establish a process to monitor 
 compliance with this subsection. Such process shall ensure that 
 each specified ambulatory surgical center's compliance with 
 this subsection is reviewed not less frequently than once every 
 year.
 ``

    (5) Enforcement.--
 ``
        (A) In general.--In the case of a specified 
 ambulatory 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 which the 
 Secretary determines such failure 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 requirements.
 ``
        (B) Civil monetary penalty.--
 ``
            (i) In general.--A specified ambulatory 
 surgical center that has received a 
 notification 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 an 
 ambulatory surgical center that has submitted a 
 corrective action plan described in 
 subparagraph
        (A)
            (ii) in response 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 day (beginning with the day 
 on which the Secretary first determined that 
 such hospital was not complying with such 
 requirements) during which such failure is 
 ongoing (not to exceed $300 per day).
 ``
            (ii) Increase authority.--In applying 
 this subparagraph with respect to violations 
 occurring in 2027 or a subsequent year, the 
 Secretary may through notice and comment 
 rulemaking increase the limitation on the per 
 day amount of any penalty applicable to a 
 specified ambulatory surgical center under 
 clause
            (i) .
 ``
            (iii) Application of certain 
 provisions.--The provisions of 

section 1128A of 
 the Social Security Act (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) No authority to waive or reduce 
 penalty.--The Secretary shall not grant or 
 extend any waiver, delay, tolling, or other 
 mitigation of a civil monetary penalty for 
 violation of this subsection.
 ``

    (6) Provision of technical assistance.--The Secretary 
 shall, to the extent practicable, provide technical assistance 
 relating to compliance with the provisions of this subsection 
 to specified ambulatory surgical centers requesting such 
 assistance.
 ``

    (7) === Definitions. ===
-For purposes of this 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 
 item or service furnished by an ambulatory surgical 
 center.
 ``
        (B) Gross charge.--The term `gross charge' means 
 the charge for an individual item or service that is 
 reflected on a specified surgical center's 
 chargemaster, absent any discounts.
 ``
            (C) Group health plan; group health insurance 
 coverage; individual health insurance coverage.--The 
 terms `group health plan', `group health insurance 
 coverage', and `individual health insurance coverage' 
 have the meaning given such terms in 

section 2791 of 
 the Public Health Service Act.
 ``
            (D) Payer-specific negotiated charge.--The term 
 `payer-specific negotiated charge' means the charge 
 that a specified surgical center has negotiated with a 
 third party payer for an item or service.
 ``
        (E) 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.
 ``
        (F) Specified ambulatory surgical center.--The 
 term `specified ambulatory surgical center' means an 
 ambulatory surgical center with respect to which a 
 hospital (or any person with an ownership or control 
 interest (as defined in 

section 1124

    (a)

    (3) of the 
 Social Security Act) in a hospital) is a person with an 
 ownership or control interest (as so defined).
 ``
        (G) 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.
 ``

    (8) Rulemaking.--The Secretary shall implement this 
 subsection through notice and comment rulemaking in accordance 
 with 

section 553 of title 5, United States Code.''.

SEC. 6. STRENGTHENING HEALTH COVERAGE TRANSPARENCY REQUIREMENTS.

    (a) Transparency in Coverage.--

Section 1311

    (e)

    (3)
            (C) of the Patient 
Protection and Affordable Care Act (42 U.S.C. 18031

    (e)

    (3)
            (C) ) is 
amended--

    (1) by striking ``The Exchange'' and inserting the 
 following:
 ``
            (i) In general.--The Exchange'';

    (2) in clause
            (i) , as inserted by paragraph

    (1) --
        (A) by striking ``participating provider'' and 
 inserting ``provider'';
        (B) by inserting ``shall include the information 
 specified in clause
            (ii) and'' after ``such 
 information'';
            (C) by striking ``an Internet website'' and 
 inserting ``a self-service tool that meets the 
 requirements of clause
            (iii) ''; and
            (D) by striking ``and such other'' and all that 
 follows through the period and inserting ``or, at the 
 option such individual, through a paper or phone 
 disclosure (as selected by such individual and provided 
 at no cost to such individual) that meets such 
 requirements as the Secretary may specify.''; and

    (3) by adding at the end the following new clauses:
 ``
            (ii) Specified information.--For purposes 
 of clause
            (i) , the information specified in 
 this clause is, with respect to benefits 
 available under a health plan for an item or 
 service furnished by a health care provider, 
 the following:
 ``
            (I) If such provider is a 
 participating provider with respect to 
 such item or service, the in-network 
 rate (as defined in subparagraph
        (F) ) 
 for such item or service.
 ``
            (II) If such provider is not 
 described in subclause
            (I) , the maximum 
 allowed dollar amount for such item or 
 service.
 ``
            (III) The amount of cost sharing 
 (including deductibles, copayments, and 
 coinsurance) that the individual will 
 incur for such item or service (which, 
 in the case such item or service is to 
 be furnished by a provider described in 
 subclause
            (II) , shall be calculated 
 using the maximum amount described in 
 such subclause).
 ``
            (IV) The amount the individual 
 has already accumulated with respect to 
 any deductible or out of pocket maximum 
 under the plan (broken down, in the 
 case separate deductibles or maximums 
 apply to separate individuals enrolled 
 in the plan, by such separate 
 deductibles or maximums, in addition to 
 any cumulative deductible or maximum).
 ``
            (V) In the case such plan imposes 
 any frequency or volume limitations 
 with respect to such item or service 
 (excluding medical necessity 
 determinations), the amount that such 
 individual has accrued towards such 
 limitation with respect to such item or 
 service.
 ``
            (VI) Any prior authorization, 
 concurrent review, step therapy, fail 
 first, or similar requirements 
 applicable to coverage of such item or 
 service under such plan.
 ``
            (iii) Self-service tool.--For purposes of 
 clause
            (i) , a self-service tool established by 
 a health plan meets the requirements of this 
 clause if such tool--
 ``
            (I) is based on an internet 
 website;
 ``
            (II) provides for real-time 
 responses to requests described in such 
 clause;
 ``
            (III) is updated in a manner such 
 that information provided through such 
 tool is timely and accurate;
 ``
            (IV) allows such a request to be 
 made with respect to an item or service 
 furnished by--
 ``

    (aa) a specific provider 
 that is a participating 
 provider with respect to such 
 item or service;
 ``

    (bb) all providers that 
 are participating providers 
 with respect to such plan and 
 such item or service; or
 ``
            (cc) a provider that is 
 not described in item

    (bb) ;
 ``
            (V) provides that such a request 
 may be made with respect to an item or 
 service through use of--
 ``

    (aa) the billing code for 
 such item or service; or
 ``

    (bb) through use of a 
 descriptive term for such item 
 or service to produce a list of 
 billing code options from which 
 the individual selects to 
 indicate the subject matter 
 items or services; and
 ``
            (VI) holds a member harmless for 
 the amount of any difference in excess 
 of the amount of the individual's 
 responsibility generated by the self-
 service tool and the amount ultimately 
 billed or charged to the individual.''.

    (b) Disclosure of Additional Information.--

Section 1311

    (e)

    (3) of 
the Patient Protection and Affordable Care Act (42 U.S.C. 18031

    (e)

    (3) ) 
is amended by adding at the end the following new subparagraphs:
 ``
        (E) Rate and payment information.--
 ``
            (i) In general.--Not later than January 
 1, 2027, and every month thereafter, each 
 health plan shall submit to the Exchange, the 
 Secretary, the State insurance commissioner, 
 and make available to the public, the rate and 
 payment information described in clause
            (ii) in 
 accordance with clause
            (iii) .
 ``
            (ii) Rate and payment information 
 described.--For purposes of clause
            (i) , the 
 rate and payment information described in this 
 clause is, with respect to a health plan, the 
 following:
 ``
            (I) With respect to each item or 
 service for which benefits are 
 available under such plan (expressed as 
 a dollar amount), including 
 prescription drugs, identified by CPT, 
 HCPCS, DRG, NDC, or other applicable 
 nationally recognized identifier, 
 including any applicable code 
 modifiers, and accompanied by a brief 
 description of the item or service, the 
 in-network rate in effect as of the 
 date of the submission of such 
 information with each provider 
 (identified by national provider 
 identifier) that is a participating 
 provider with respect to such item or 
 service, other than such a rate in 
 effect with a provider--
 ``

    (aa) that has submitted 
 no claims; and
 ``

    (bb) expects to receive 
 no claims in the then 
 applicable calendar year for 
 such item or service to such 
 plan.
 ``
            (II) With respect to each drug 
 (identified by National Drug Code, J-
 code, or other commonly recognized 
 billing code used for drugs) for which 
 benefits are available under such plan:
 ``

    (aa) The in-network rate 
 (expressed as a dollar amount), 
 including the individual and 
 total amounts for any bundled 
 rates, in effect as of the 
 first day of the month in which 
 such information is made public 
 with each provider that is a 
 participating provider with 
 respect to such drug.
 ``

    (bb) The historical net 
 price paid by such plan (net of 
 rebates, discounts, and price 
 concessions) (expressed as a 
 dollar amount) for such drug 
 dispensed or administered 
 during the 90-day period 
 beginning 180 days before such 
 date of submission to each 
 provider that was a 
 participating provider with 
 respect to such drug, broken 
 down by each such provider 
 (identified by national 
 provider identifier), other 
 than such an amount paid to a 
 provider that has submitted no 
 claims for such drug to such 
 plan.
 ``
            (III) With respect to each item 
 or service for which benefits are 
 available under such plan (expressed as 
 a dollar amount), identified by CPT, 
 DRG, HCPCS, NDC, or other applicable 
 nationally recognized identifier, 
 including any applicable code 
 modifiers, and accompanied by a brief 
 description of the item or service, the 
 amount billed or charged by the 
 provider, and the amount allowed by the 
 plan, for each such item or service 
 furnished during the 90-day period 
 beginning 180 days before such date of 
 submission by each provider that was 
 not a participating provider with 
 respect to such item or service, broken 
 down by each such provider (identified 
 by national provider identifier), other 
 than items and services with respect to 
 which no claims for such item or 
 service were submitted to such plan 
 during such period.
 ``
            (iii) Manner of submission.--Rate and 
 payment information required to be submitted 
 and made available under this subparagraph 
 shall be so submitted and so made available as 
 follows:
 ``
            (I) Information shall be 
 contained in 3 separate machine-
 readable files corresponding to the 
 information described in each of 
 subclauses
            (I) through
            (III) of clause
            (ii) that meet such requirements as 
 specified by the Secretary through 
 rulemaking, in consultation with the 
 Secretaries of Labor and the Treasury 
 to apply comparable requirements to 
 group health plans and to entities 
 providing benefit management or other 
 third-party administration services on 
 a contractual basis with a group health 
 plan.
 ``
            (II) Requirements specified by 
 the Secretary through rulemaking shall 
 ensure that:
 ``

    (aa) Such files are 
 limited to an appropriate size, 
 are made available in a widely 
 available format that allows 
 for information contained in 
 such files to be compared 
 across health plans, and are 
 accessible to individuals at no 
 cost and without the need to 
 establish a user account or 
 provider other credentials.
 ``

    (bb) The rates, amounts, 
 and prices to be disclosed 
 include contractual terms 
 containing calculation 
 formulae, pricing 
 methodologies, and other 
 information necessary to 
 determine the dollar value of 
 reimbursement.
 ``
            (cc) Each such file 
 includes each of the following 
 data elements:

 ``

    (AA) A numerical 
 identifier for the 
 group health plan and/
 or health insurance 
 issuer (such as a 
 Health Insurance 
 Oversight System 
 identifier).

 ``

    (BB) A plain-
 language description of 
 the item or service 
 (including, for drugs, 
 the proprietary and 
 nonproprietary name 
 assigned).

 ``
            (CC) The billing 
 code, including any 
 applicable modifiers, 
 associated with such 
 item or service, 
 including the 
 Healthcare Common 
 Procedure Coding System 
 code, diagnosis-related 
 group, national drug 
 code, or other commonly 
 recognized code set.

 ``
            (DD) The place of 
 service code.

 ``

    (EE) The National 
 Provider Identifier or 
 provider Tax 
 Identification Number.

 ``
            (III) The rate and payment 
 information disclosed under subclauses
            (I) through
            (III) of clause
            (ii) shall 
 be separately delineated for each item 
 or service, regardless of whether such 
 item or service is reimbursed as a part 
 of a bundle, episode, or other grouping 
 of items and services.
 ``
            (IV) An officer or executive of 
 competent authority shall attest to the 
 accuracy and completeness of 
 information submitted and made 
 available under this subparagraph. Such 
 attestation shall be subject to 
 enforcement under subparagraph
        (H) and, 
 where applicable, shall be deemed 
 material to payments from the Federal 
 Government received by the group health 
 plan or health insurance issuer.
 ``
            (V) Regulations promulgated 
 pursuant to this section shall provide 
 that:
 ``

    (aa) The Secretary shall 
 audit the three machine-
 readable files required by 
 subparagraph
        (E)
            (ii) posted by 
 no fewer than 20 group health 
 plans or health insurance 
 issuers.
 ``

    (bb) The Secretary of 
 Labor shall audit the three 
 machine-readable files required 
 by subparagraph
        (E)
            (ii) posted 
 by no fewer than 200 group 
 health plans or service 
 providers furnishing third-
 party administrator services to 
 a group health plan.
 ``
            (cc) Findings, 
 conclusions, and enforcement 
 actions taken based on audits 
 of the machine-readable files 
 shall be reported annually to 
 Congress no later than July 1 
 of the calendar year during 
 which the files were audited. 
 Such report to Congress shall 
 be accessible to the public.
 ``
            (iv) User guide.--Each health plan shall 
 make available to the public instructions 
 written in plain language explaining how 
 individuals may search for information 
 described in clause
            (ii) in files submitted in 
 accordance with clause
            (iii) .
 ``
        (F) === Definitions. ===
-In this paragraph:
 ``
            (i) Participating provider.--The term 
 `participating provider' has the meaning given 
 such term in 

section 2799A-1 of the Public 
 Health Service Act.
 ``
            (ii) In-network rate.--The term `in-
 network 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 service. If the 
 rate is based on an algorithm, percentage of 
 another amount, or other formula or criteria, 
 the health plan also shall disclose such 
 algorithm, percentage, formula, or criteria as 
 set forth in its contract and any other terms, 
 schedules, exhibits, data, or other information 
 referenced in any such contract as shall be 
 required to determine and disclose the 
 negotiated rate.
 ``
        (G) Applicability to accountable care 
 organizations.--An applicable ACO participating in the 
 Medicare Shared Savings Program, as defined in 

Section 1899 of the Social Security Act (42 U.S.C. 1395jjj), 
 shall be subject to the requirements of this paragraph 
 as if such applicable ACO is a group health plan or 
 health insurance issuer.
 ``
        (H) Enforcement.--
 ``
            (i) In general.--Each year, the Secretary 
 shall audit the three machine-readable files 
 required by subparagraph
        (E)
            (ii) posted by no 
 fewer than 20 group health plans or health 
 insurance issuers.
 ``
            (ii) Notification and request for 
 corrective action.--In the case of a health 
 plan that fails to comply with the requirements 
 of this subsection, not later than 30 days 
 after the date on which the Secretary 
 determines such failure exists, the Secretary 
 shall submit to such health plan a notification 
 of such determination, which shall include a 
 request for a corrective action plan to comply 
 with such requirements.
 ``
            (iii) Civil monetary penalty.--A health 
 plan that has received a request for a 
 corrective action plan under clause
            (ii) and 
 fails to comply with the requirements of this 
 subsection by the date that is 90 days after 
 such request is made shall be subject to a 
 civil monetary penalty of an amount specified 
 by the Secretary for each day (beginning with 
 the day on which the Secretary first determined 
 that such laboratory was failing to comply with 
 such paragraph) during which such failure was 
 ongoing. Such amount shall not exceed $300 per 
 member per day or $10,000,000, whichever is 
 lesser.
 ``
            (I) Rulemaking.--The Secretary shall implement 
 subparagraphs
        (E) through
        (H) through notice and 
 comment rulemaking in accordance with 

section 553 of 
 title 5, United States Code.''.
            (c) Effective Date.--

    (1) In general.--The amendments made by subsections

    (a) and

    (b) shall apply beginning January 1, 2026.

    (2) Continued applicability of rules for previous years.--
 Nothing in the amendments made by this section may be construed 
 as affecting the applicability of the rule entitled 
 ``Transparency in Coverage'' published by the Department of the 
 Treasury, the Department of Labor, and the Department of Health 
 and Human Services on November 12, 2020 (85 Fed. Reg. 72158) 
 before January 1, 2026.

SEC. 7. INCREASING GROUP HEALTH PLAN ACCESS TO HEALTH DATA.

    (a) Group Health Plan Access to Information.--

    (1) In general.--Paragraph

    (2) of 

section 408

    (b) of the 
 Employee Retirement Income Security Act of 1974 (29 U.S.C. 
 1108

    (b) ) is amended by adding at the end the following new 
 subparagraphs:
 ``
            (C) No contract or arrangement for services, and 
 no extension or renewal of such contract or 
 arrangement, between a group health plan (as that term 
 is defined in 

section 733

    (a) of this title) and party 
 in interest, including a health care provider (which 
 for purposes of this subparagraph, includes a health 
 care facility), network or association of providers, 
 service provider offering access to a network of 
 providers, third-party administrator, or pharmacy 
 benefit manager (collectively referred to as `Covered 
 Service Providers'), is reasonable within the meaning 
 of this paragraph unless such contract or arrangement--
 ``
            (i) allows the responsible plan fiduciary 
 (as that term is defined in subparagraph
        (B)
            (ii) 
            (I) (ee) ) access to all claims and 
 encounter information or data, and any 
 documentation supporting claim payments, 
 including, but not limited to, medical records 
 and policy documents, or information or data 
 described in 

section 724

    (a)

    (1)
        (B) to--
 ``
            (I) enable such entity to comply 
 with the terms of the plan and any 
 applicable law; and
 ``
            (II) determine the accuracy or 
 reasonableness of payment; and
 ``
            (ii) does not--
 ``
            (I) unreasonably limit or delay 
 access, as determined by the Secretary 
 but in any event not longer than 15 
 days, to such information or data;
 ``
            (II) limit the volume of claims 
 and encounter information or data that 
 the group health plan, the plan 
 sponsor, the plan administrator, or a 
 business associate of such plan may 
 access during an audit or pursuant to 
 any request for such information or 
 data;
 ``
            (III) limit the disclosure of 
 pricing terms for value-based payment 
 arrangements or capitated payment 
 arrangements, including--
 ``

    (aa) payment calculations 
 and formulas;
 ``

    (bb) quality measures;
 ``
            (cc) contract terms;
 ``
            (dd) payment amounts;
 ``

    (ee) measurement periods 
 for all incentives; and
 ``

    (ff) other payment 
 methodologies used by an 
 entity, including a health care 
 provider (including a health 
 care facility), network or 
 association of providers, 
 service provider offering 
 access to a network of 
 providers, third-party 
 administrator, or pharmacy 
 benefit manager;
 ``
            (IV) limit the disclosure of 
 overpayments and overpayment recovery 
 terms;
 ``
            (V) limit the right of the group 
 health plan, the plan sponsor, or the 
 plan administrator of such plan to 
 select an auditor or define audit scope 
 or frequency;
 ``
            (VI) otherwise limit or unduly 
 delay the group health plan, the plan 
 sponsor, the plan administrator, or a 
 business associate of such plan from 
 accessing claims and encounter 
 information or data in a daily batch;
 ``
            (VII) limit the disclosure of 
 fees charged to the group health plan 
 related to plan administration and 
 claims processing, including 
 renegotiation fees, access fees, 
 repricing fees, or enhanced review 
 fees;
 ``
            (VIII) limit the right of the 
 group health plan, the plan sponsor, or 
 the plan administrator to request 
 action on any suspect claim payments; 
 or
 ``
            (IX) limit public disclosure of 
 de-identified or aggregate information.
 ``
            (D) 
            (i) Covered Service Providers shall provide 
 information or data under this paragraph in a manner 
 consistent with the privacy and security regulations 
 promulgated under the Health Insurance Portability and 
 Accountability Act (referred to in this subparagraph as 
 `HIPAA').
 ``
            (ii) A group health plan that receives a 
 disclosure from a party in interest pursuant to 
 subparagraph
        (B) or
            (C) shall comply with the privacy 
 and security regulations promulgated under HIPAA.
 ``
            (iii) Nothing in this subparagraph shall be 
 construed to modify the requirements for the creation, 
 receipt, maintenance, or transmission of protected 
 health information under the HIPAA privacy regulation 
 (as defined in 

section 1180

    (b)

    (3) of the Social 
 Security Act) as they apply directly or indirectly to 
 an entity pursuant to this paragraph.
 ``
            (iv) This subparagraph shall not be read to 
 abridge or limit the disclosure requirements under this 
 paragraph or to impose additional privacy or security 
 requirements on Covered Service Providers or plan 
 sponsors.
 ``
        (E) A group health plan receiving information or 
 data under this paragraph may disclose such information 
 only in a manner that is consistent with the Health 
 Insurance Portability and Accountability Act

    (HIPAA) and the privacy and security regulations promulgated 
 thereunder, regardless of their direct or indirect 
 applicability to the plan or any entities that could be 
 or are business associates.
 ``
        (F) Information made available under this section 
 shall conform to the following standards:
 ``
            (i) All claims from a healthcare provider 
 shall be made to the group health plan in 
 accordance with transaction standards adopted 
 by regulation under HIPAA, as follows:
 ``
            (I) Institutional, professional, 
 and dental claims shall be in ASC X12N 
 837 format or any subsequent standard.
 ``
            (II) Pharmacy claims shall be in 
 the National Council for Prescription 
 Drug Programs

    (NCPDP) format or any 
 subsequent standard.
 ``
            (III) The files shall be 
 unmodified copies of the files sent 
 from the provider. In the event that 
 paper claims are sent by the provider, 
 they shall be converted to the 
 appropriate standard electronic format. 
 Files shall be accessible to the plan 
 at no cost to the group health plan.
 ``
            (ii) All claim payment (or EFT, 
 electronic funds transfer) and electronic 
 remittance advice

    (ERA) notices sent by a 
 Covered Service Provider shall be made 
 available to the group health plan as ASC X12N 
 835 files in accordance with standards adopted 
 by regulation under HIPAA. The files shall be 
 unmodified copies of the files sent by the 
 Covered Service Provider to the healthcare 
 provider. Files shall be accessible at no cost 
 to the group health plan.
 ``
            (iii) The contractual terms containing 
 calculation formulae, pricing methodologies, 
 and other information used to determine the 
 dollar value of reimbursement.
 ``
            (iv) All non-claim costs shall be 
 itemized and made available to the group health 
 plan in real time through a web-based portal, 
 through an API, and through a downloadable CSV 
 file.
 ``
        (G) The Secretary shall implement subparagraphs
            (C) through
        (F) through notice and comment rulemaking 
 in accordance with 

section 553 of title 5, United 
 States Code.''.

    (2) Civil enforcement.--Subsection
            (c) of 

section 502 of 
 such Act (29 U.S.C. 1132) is amended by adding at the end the 
 following new paragraph:
 ``

    (13) In the case of an agreement between a group health 
 plan (as defined in 

section 733

    (a) ), the plan sponsor of such 
 plan (as defined in 

section 3

    (16)
        (B) ), or the plan 
 administrator of such plan (as defined in 

section 3

    (16)
        (A) ) and 
 a health care provider (which, for purposes of this paragraph, 
 includes a health care facility), network or association of 
 providers, service provider offering access to a network or 
 association of providers, third-party administrator, or 
 pharmacy benefit manager, that violates the provisions of 
 

section 724, the Secretary may assess a civil penalty against 
 such provider, network or association, service provider 
 offering access to a network or association of providers, 
 third-party administrator, pharmacy benefit manager, or other 
 service provider in the amount of $10,000 for each day during 
 which such violation continues. Such penalty shall be in 
 addition to other penalties as may be prescribed by law.''.

    (3) Existing provisions void.--

Section 410 of such Act (29 
 U.S.C. 1110) is amended by adding at the end the following:
 ``
            (c) Any provision in an agreement or instrument shall be void as 
against public policy if such provision--
 ``

    (1) unduly delays or limits a group health plan (as 
 defined in 

section 733

    (a) ), the plan sponsor of such plan (as 
 defined in 

section 3

    (16)
        (B) ), or the plan administrator of such 
 plan (as defined in 

section 3

    (16)
        (A) ) from accessing the claims 
 and encounter information or data described in 

section 724

    (a)

    (1)
        (B) ; or
 ``

    (2) violates the requirements of 

section 408

    (b)

    (2)
            (C) .''.

    (4) Technical amendment.--Clause
            (i) of 

section 408

    (b)

    (2)
        (B) of such Act is amended by striking ``this clause'' 
 and inserting ``this paragraph''.

    (b) Updated Attestation for Price and Quality Information.--

Section 724

    (a)

    (3) of the Employee Retirement Income Security Act of 1974 (29 
U.S.C. 1185m

    (a)

    (3) ) is amended to read as follows:
 ``

    (3) Attestation.--
 ``
        (A) In general.--Subject to subparagraph
            (C) , a 
 group health plan or health insurance issuer offering 
 group health insurance coverage shall annually submit 
 to the Secretary an attestation that such plan or 
 issuer of such coverage is in compliance with the 
 requirements of this subsection. Such attestation shall 
 also include a statement verifying that--
 ``
            (i) the information or data described 
 under subparagraphs
        (A) and
        (B) of paragraph

    (1) is available upon request and provided to 
 the group health plan, the plan sponsor, the 
 plan administrator, or the business associate 
 of such plan, or the issuer in a timely manner; 
 and
 ``
            (ii) there are no terms in the agreement 
 under such paragraph

    (1) that directly or 
 indirectly restrict or unduly delay a group 
 health plan, the plan sponsor, the plan 
 administrator, a business associate of such 
 plan, or the issuer from auditing, reviewing, 
 or otherwise accessing such information.
 ``
        (B) Limitation on submission.--Subject to clause
            (ii) , a group health plan or issuer offering group 
 health insurance coverage may not enter into an 
 agreement with a third-party administrator or other 
 service provider to submit the attestation required 
 under subparagraph
        (A) .
 ``
            (C) Exception.--In the case of a group health 
 plan or issuer offering group health insurance coverage 
 that is unable to obtain the information or data needed 
 to submit the attestation required under subparagraph
        (A) , such plan or issuer may submit a written statement 
 in lieu of such attestation that includes--
 ``
            (i) an explanation of why such plan or 
 issuer was unsuccessful in obtaining such 
 information or data, including whether such 
 plan, the plan sponsor, or the plan 
 administrator or issuer was limited or 
 prevented from auditing, reviewing, or 
 otherwise accessing such information or data;
 ``
            (ii) a description of the efforts made by 
 the group health plan, the plan sponsor, or the 
 plan administrator to remove any gag clause 
 provisions from the agreement under paragraph

    (1) ; and
 ``
            (iii) a description of any response by 
 the third-party administrator or other service 
 provider with respect to efforts to comply with 
 the attestation requirement under subparagraph
        (A) , including the name of the third-party 
 administrator or other service provider.''.
            (c) Effective Date.--The amendments made by subsections

    (a) and

    (b) shall apply with respect to a plan beginning with the first plan year 
that begins on or after the date that is 1 year after the date of 
enactment of this Act.

SEC. 8. OVERSIGHT OF ADMINISTRATIVE SERVICE PROVIDERS.

    (a) ERISA Amendments.--

    (1) In general.--Subpart B of part 7 of subtitle B of the 
 Employee Retirement Income Security Act of 1974 (29 U.S.C. 1021 
 et seq.) is amended by adding at the end the following:

``

SEC. 726. OVERSIGHT OF ADMINISTRATIVE SERVICE PROVIDERS.

 ``

    (a) In General.--For plan years beginning on or after the date 
that is 2 years after the date of enactment of this section, no 
agreement between a group health plan (as defined in 

section 733

    (a) ), 
the plan sponsor of such plan (as defined in 

section 3

    (16)
        (B) ), the 
plan administrator of such plan (as defined in 

section 3

    (16)
        (A) ), or a 
business associate of such plan (as defined in 

section 160.103 of title 
45, Code of Federal Regulations), (or health insurance issuer offering 
group health insurance coverage in connection with such a plan), and a 
health care provider, network or association of providers, third-party 
administrator, service provider offering access to a network of 
providers, pharmacy benefit managers, or any other third party (each 
referred to as a `health plan service provider') is permissible if such 
agreement limits (or delays beyond the applicable reporting period 
described in subsection

    (b)

    (1) ) the disclosure of information to group 
health plans in such a manner that prevents such plan, issuer, or 
entity from providing the information described in subsection

    (b) .
 ``

    (b) Required Disclosures.--
 ``

    (1) Contents and frequency.--With respect to plan years 
 beginning on or after the date that is 2 years after the date 
 of enactment of this section, not less frequently than 
 quarterly, a health plan service provider shall provide to the 
 group health plan or health insurance issuer the following 
 information at no cost to the group health plan or health 
 insurance issuer:
 ``
        (A) The information described in 

section 724

    (a)

    (1)
        (B) .
 ``
        (B) Any contractual and subcontractual 
 calculation methodologies, pricing or fee schedules, or 
 other formulae used to determine reimbursement amounts 
 to providers and subcontractors, including 
 methodologies, schedules, fee structures, and any 
 applied adjustments or modifiers, with such information 
 provided in a manner sufficiently detailed to enable 
 the group health plan or health insurance issuer to 
 accurately assess, verify, and ensure compliance with 
 the terms of any contractual and subcontractual 
 agreement governing the reimbursement amounts.
 ``
            (C) The total amount received or expected to be 
 received by the health plan service provider or its 
 subcontractors in provider or supplier rebates, fees, 
 alternative discounts, and all other remuneration 
 including amounts held in escrow or variance accounts 
 that has been paid or is to be paid for claims incurred 
 and administrative services including data sales or 
 network payments.
 ``
            (D) The total amount paid or expected to be paid 
 by the health plan service provider or to 
 subcontractors in rebates, fees, contractual 
 arrangements, and all other remuneration that has been 
 paid or is expected to be paid for administrative and 
 other services.
 ``
        (E) All payment data and reconciliation 
 information related to alternative compensation 
 arrangements including accountable care organizations, 
 value-based programs, shared savings programs, 
 incentive compensation, bundled payments, capitation 
 arrangements, performance payments, and any other 
 reimbursement or payment models, where the group health 
 plan or health insurance issuer paid fees, incurred 
 obligations, or made payments in connection with the 
 group health plan related to such arrangements.
 ``

    (2) Privacy requirements.--
 ``
        (A) In general.--Health plan service providers 
 shall provide the information or data under paragraph

    (1) consistent with the privacy, security, and breach 
 notification regulations at parts 160 and 164 of title 
 45, Code of Federal Regulations, promulgated under 
 subtitle F of the Health Insurance Portability and 
 Accountability Act of 1996, subtitle D of the Health 
 Information Technology for Clinical Health Act of 2009, 
 and 

section 1180 of the Social Security Act, and shall 
 restrict the use and disclosure of such information 
 according to such privacy, security, and breach 
 notification regulations. An entity that receives a 
 disclosure from a party in interest pursuant to 
 subparagraph
        (B) or
            (C) shall comply with the privacy 
 and security regulations promulgated under HIPAA.
 ``
        (B) Restrictions.--A group health plan shall 
 comply with 

section 164.504

    (f) of title 45, Code of 
 Federal Regulations (or a successor regulation), and a 
 plan sponsor shall act in accordance with the terms of 
 the agreement described in such section.
 ``
            (C) Rule of construction.--Nothing in this 
 section shall be construed to modify the requirements 
 for the creation, receipt, maintenance, or transmission 
 of protected health information under the HIPAA privacy 
 regulations (45 C.F.R. parts 160 and 164, subparts A 
 and E).
 ``

    (3) Disclosure and redisclosure.--
 ``
        (A) In general.--A group health plan receiving 
 information under paragraph

    (1) may disclose such 
 information only--
 ``
            (i) to the entity from which the 
 information was received or to that entity's 
 business associates or to the group health 
 plan's business associates as defined in 
 

section 160.103 of title 45, Code of Federal 
 Regulations (or successor regulations); or
 ``
            (ii) as permitted by the HIPAA Privacy 
 Rule (45 C.F.R. parts 160 and 164, subparts A 
 and E).
 ``
        (B) Availability of information.--To the extent 
 the information required by this subsection is made 
 available to the health insurance issuer offering group 
 health insurance in connection with a group health 
 plan, the health insurance issuer shall make such 
 information available, at the same time, in the same 
 format, and at no cost, to the group health plan.
 ``
            (C) Failure to provide.--The obligation to 
 provide information pursuant to this subsection shall 
 exist notwithstanding the presence of any formal data-
 sharing agreement between the parties. Failure to 
 provide the required information as specified shall 
 constitute a violation of this Act and the Secretary 
 shall initiate enforcement action under 

section 502 
 within 90 days of becoming aware of a violation of this 
 section, except that nothing in this section shall be 
 construed to limit the Secretary's existing authority 
 under the Act.
 ``

    (4) Data format standards.--All data and information 
 provided pursuant to this subsection shall comply with the 
 following standards:
 ``
        (A) All claims from a healthcare provider shall 
 be made to the group health plan in accordance with 
 transactions standards adopted under HIPAA, as follows:
 ``
            (i) Institutional, professional, and 
 dental claims and adjustments to these claims 
 shall be in ASC X12N 837 format, as transmitted 
 by the provider, or, in the case of paper 
 claims, converted to the ASC X12N 837 
 electronic format.
 ``
            (ii) Prescription drug claims shall be in 
 the National Council for Prescription Drug 
 Programs

    (NCPDP) format, as transmitted by the 
 provider, or in the case of paper claims, 
 converted to the NCPDP electronic format.
 ``
            (iii) Such data shall be provided at no 
 cost to the group health plan.
 ``
        (B) All claim payment (or EFT, electronic funds 
 transfer) and electronic remittance advice

    (ERA) information sent by a health plan service provider 
 shall be provided to the group health plan or health 
 insurance issuer in the ASC X12N 835 format in 
 accordance with transaction standards adopted under 
 HIPAA, unmodified from the form in which it was 
 transmitted to the healthcare provider. Such 
 information shall be provided at no cost to the group 
 health plan or health insurance issuer.
 ``
            (C) The Secretary may modify the standards set 
 forth in this paragraph as necessary to align with any 
 changes adopted by the Secretary of Health and Human 
 Services pursuant to the authority provided under 
 

section 1173 of the Social Security Act (42 U.S.C. 
 1320d-2).
 ``
            (c) Prohibited Contractual Provisions.--Any provision in an 
agreement between a group health plan, the plan sponsor, the plan 
administrator, or a business associate of such plan or a health 
insurance issuer and a health plan service provider that unduly delays 
or limits a group health plan's or health insurance issuer's access to 
information described in this section or that restricts the format or 
timing of the provision of such information in a manner that is 
inconsistent with the requirements of this section shall be prohibited 
and, if a group health plan or health insurance issuer enters into such 
agreement, shall be deemed void as against public policy.
 ``
            (d) Penalties for Non-Compliance.--Any failure by a health plan 
service provider to comply with the requirements of this section shall 
result in the imposition of a civil penalty of $100,000 for each day 
the violation continues, in addition to any other penalties prescribed 
by law.
 ``

    (e) Regulations.--The Secretary shall implement this section 
through notice and comment rulemaking in accordance with 

section 553 of 
title 5, United States Code.''.

    (2) Penalty.--
        (A) In general.--

Section 502

    (a) of the Employee 
 Retirement Income Security Act of 1974 (29 U.S.C. 
 1132

    (a) ) is amended by adding at the end the following 
 new paragraph:
 ``

    (14) The Secretary may assess a civil penalty against any 
 person of $100,000 per day for each violation by any person of 
 

section 726.''.
        (B) Technical amendment.--Paragraph

    (6) of 

section 502

    (a) of the Employee Retirement Income Security Act 
 of 1974 (29 U.S.C. 1132

    (a) ) is amended by striking ``or

    (9) '' and inserting it with the phrase ``

    (9) ,

    (13) , or

    (14) ''.

    (b) PHSA Amendments.--

    (1) In general.--Part D of title XXVII of the Public Health 
 Service Act (42 U.S.C. 300gg-111 et seq.) is amended by adding 
 at the end the following:

``

SEC. 2799A-11. OVERSIGHT OF ADMINISTRATIVE SERVICE PROVIDERS.

 ``

    (a) In General.--For plan years beginning on or after the date 
that is 1 year after the date of enactment of this section, no 
agreement between a group health plan that is a self-funded, non-
Federal governmental plan, as defined in 

section 2791
            (d) (8)
            (C) (42 
U.S.C. 300gg-91
            (d) (8)
            (C) ), and a health care provider, network or 
association of providers, third-party administrator, service provider 
offering access to a network of providers, pharmacy benefit managers, 
or any other third party (each referred to in this section as a `health 
plan service provider') is permissible if such agreement limits (or 
delays beyond the applicable reporting period described in subsection

    (b)

    (1) ) the disclosure of information to group health plans in such a 
manner that prevents such plan, issuer, or entity from providing the 
information described in subsection

    (b) .
 ``

    (b) Required Disclosures.--
 ``

    (1) Contents and frequency.--With respect to plan years 
 beginning on or after the date that is 1 year after the date of 
 enactment of this section, not less frequently than quarterly, 
 a health plan service provider shall provide to the group 
 health plan that is a self-funded, non-Federal governmental 
 plan the following information at no cost to the plan:
 ``
        (A) The information described in 

section 2799A-
 9

    (a)

    (1)
        (B) (42 U.S.C. 300gg-119

    (a)

    (1)
        (B) ).
 ``
        (B) Any contractual and subcontractual 
 calculation methodologies, pricing or fee schedules, or 
 other formulae used to determine reimbursement amounts 
 to providers and subcontractors, including 
 methodologies, schedules, fee structures, and any 
 applied adjustments or modifiers, with such information 
 provided in a manner sufficiently detailed to enable 
 the group health plan to accurately assess, verify, and 
 ensure compliance with the terms of any contractual and 
 subcontractual agreement governing the reimbursement 
 amounts.
 ``
            (C) The total amount received or expected to be 
 received by the health plan service provider or its 
 subcontractors in provider or supplier rebates, fees, 
 alternative discounts, and all other remuneration 
 including amounts held in escrow or variance accounts 
 that has been paid or is to be paid for claims incurred 
 and administrative services including data sales or 
 network payments.
 ``
            (D) The total amount paid or expected to be paid 
 by the health plan service provider or to 
 subcontractors in rebates, fees, contractual 
 arrangements, and all other remuneration that has been 
 paid or is expected to be paid for administrative and 
 other services.
 ``
        (E) All payment data and reconciliation 
 information related to alternative compensation 
 arrangements including accountable care organizations, 
 value-based programs, shared savings programs, 
 incentive compensation, bundled payments, capitation 
 arrangements, performance payments, and any other 
 reimbursement or payment models, where the group health 
 plan paid fees, incurred obligations, or made payments 
 in connection with the group health plan related to 
 such arrangements.
 ``

    (2) Privacy requirements.--
 ``
        (A) In general.--Health plan service providers 
 shall provide the information or data under paragraph

    (1) consistent with the privacy, security, and breach 
 notification regulations at parts 160 and 164 of title 
 45, Code of Federal Regulations, promulgated under 
 subtitle F of the Health Insurance Portability and 
 Accountability Act of 1996, subtitle D of the Health 
 Information Technology for Clinical Health Act of 2009, 
 and 

section 1180 of the Social Security Act, and shall 
 restrict the use and disclosure of such information 
 according to such privacy, security, and breach 
 notification regulations. An entity that receives a 
 disclosure from a party in interest pursuant to 
 subparagraph
        (B) or
            (C) shall comply with the privacy 
 and security regulations promulgated under HIPAA.
 ``
        (B) Restrictions.--A group health plan that is a 
 self-funded, non-Federal governmental plan shall comply 
 with 

section 164.504

    (f) of title 45, Code of Federal 
 Regulations (or a successor regulation), and a plan 
 sponsor shall act in accordance with the terms of the 
 agreement described in such section.
 ``
            (C) Rule of construction.--Nothing in this 
 section shall be construed to modify the requirements 
 for the creation, receipt, maintenance, or transmission 
 of protected health information under the HIPAA privacy 
 regulations (45 C.F.R. parts 160 and 164, subparts A 
 and E).
 ``

    (3) Disclosure and redisclosure.--
 ``
        (A) In general.--A group health plan that is a 
 self-funded, non-Federal governmental plan receiving 
 information under paragraph

    (1) may disclose such 
 information only--
 ``
            (i) to the entity from which the 
 information was received or to that entity's 
 business associates as defined in 

section 160.103 of title 45, Code of Federal 
 Regulations (or successor regulations); or
 ``
            (ii) as permitted by the HIPAA Privacy 
 Rule (45 C.F.R. parts 160 and 164, subparts A 
 and E).
 ``
        (B) Rule of construction.--Nothing in this 
 section shall be construed to prevent a group health 
 plan that is a self-funded, non-Federal governmental 
 plan, or a health plan service provider providing 
 services with respect to such a plan, from placing 
 reasonable restrictions on the public disclosure of the 
 information described in paragraph

    (1) , except that 
 such plan or entity may not restrict disclosure of such 
 information to the Department of Health and Human 
 Services, the Department of Labor, the Department of 
 the Treasury, or the Comptroller General of the United 
 States.
 ``
            (C) Failure to provide.--The obligation to 
 provide information pursuant to this subsection shall 
 exist notwithstanding the presence of any formal data-
 sharing agreement between the parties. Failure to 
 provide the required information as specified shall 
 constitute a violation of this Act and the Secretary 
 shall initiate enforcement action under 

section 2723

    (b) (42 U.S.C. 300gg-22

    (b) ) within 90 days of becoming 
 aware of a violation of this section, except that 
 nothing in this section shall be construed to limit the 
 Secretary's existing authority under this Act.
 ``

    (4) Data format standards.--All data and information 
 provided pursuant to this subsection shall comply with the 
 following standards:
 ``
        (A) All claims from a healthcare provider shall 
 be made to the group health plan in accordance with 
 standards adopted under HIPAA at 

section 162.1101 of 
 title 45, Code of Federal Regulations, as follows:
 ``
            (i) Institutional, professional, and 
 dental claims and adjustments to these claims 
 shall be provided to the group health plan that 
 is a self-funded, non-Federal governmental plan 
 in the ASC X12N 837 format.
 ``
            (ii) Prescription drug claims shall be in 
 the National Council for Prescription Drug 
 Programs

    (NCPDP) format.
 ``
            (iii) The files shall be unmodified 
 copies of the files sent from the provider. In 
 the event that paper claims are sent by the 
 provider, they shall be converted to the 
 appropriate standard electronic format. Such 
 data shall be provided at no cost to the group 
 health plan.
 ``
        (B) All claim payment (or EFT, electronic funds 
 transfer) and electronic remittance advice

    (ERA) information sent by a health plan service provider 
 shall be provided to the group health plan or health 
 insurance issuer in the ASC X12N 835 format, in 
 accordance with standards adopted under HIPAA at 
 

section 162.1602 of title 45, Code of Federal 
 Regulations, unmodified from the form in which it was 
 transmitted to the healthcare provider. Such 
 information shall be provided at no cost to the group 
 health plan.
 ``
            (C) The Secretary may modify the standards set 
 forth in this paragraph as necessary to align with any 
 changes adopted by the Secretary pursuant to the 
 authority provided under 

section 1173 of the Social 
 Security Act (42 U.S.C. 1320d-2).
 ``
            (c) Prohibited Contractual Provisions.--Any provision in an 
agreement that unduly delays or limits a group health plan that is a 
self-funded, non-Federal governmental plan's access to information 
described in this section or that restricts the format or timing of the 
provision of such information in a manner that is inconsistent with the 
requirements of this section shall be prohibited and, if a self-funded, 
non-Federal governmental plan enters into such agreement, shall be 
deemed void as against public policy.
 ``
            (d) Regulations.--The Secretary shall implement this section 
through notice and comment rulemaking in accordance with 

section 553 of 
title 5, United States Code.''.

    (2) Penalty.--

Section 2723

    (b) of the Public Health Service 
 Act (42 U.S.C. 300gg-22

    (b) ) is amended by adding at the end the 
 following:
 ``

    (4) Enforcement authority relating to health plan service 
 providers.--Notwithstanding any provisions to the contrary, the 
 Secretary may assess a penalty against a health plan service 
 provider, as defined in 

section 2799A-11

    (a) (42 U.S.C. 300gg-
 121

    (a) ), of $100,000 per day for each violation of such 
 section, pursuant to substantially similar processes and 
 procedures as those set forth in 

section 2723

    (b)

    (2)
            (D) through
        (G) (42 U.S.C. 300gg-121

    (b)

    (2)
            (D) through
        (G) ).''.

SEC. 9. STATE PREEMPTION ONLY IN EVENT OF CONFLICT.

 The provisions of sections 2 through 5 (including the amendments 
made by such sections) shall not supersede any provision of State law 
which establishes, implements, or continues in effect any requirement 
or prohibition related to health care price transparency, including 
hospital, clinical diagnostic laboratory tests, imaging services, and 
ambulatory surgical center, except to the extent that such requirement 
or prohibition prevents the application of a requirement or prohibition 
of such sections (or amendment). Nothing in this section shall be 
construed to affect group health plans established under the Employee 
Retirement Income Security Act of 1974, or alter the application of 

section 514 of such Act (29 U.S.C. 1144).

SEC. 10. REQUIREMENT FOR EXPLANATION OF BENEFITS.

    (a) PHSA Amendments.--

    (1) Emergency services.--

Section 2799A-1

    (f)

    (1)
            (C) of the 
 Public Health Service Act (42 U.S.C. 300gg-111

    (f)

    (1)
            (C) ) is 
 amended to read as follows:
 ``
            (C) A good faith estimate of the amount the plan 
 or coverage is responsible for paying for items and 
 services included in the estimate described in 
 subparagraph
        (B) , including a plain language 
 description of each item or service and all applicable 
 billing codes for each item or service, including 
 modifiers, using standard and commonly recognized 
 billing code sets that are clearly identified.''.

    (2) Explanation of benefits.--

Section 2799A-1 of the Public 
 Health Service Act (42 U.S.C. 300gg-111) is amended by adding 
 at the end the following:
 ``

    (g) Explanation of Benefits.--
 ``

    (1) In general.--For plan years beginning on or after 
 January 1, 2026, each group health plan, or a health insurance 
 issuer offering group or individual health insurance coverage 
 shall, within 45 days of receiving any request for payment for 
 an item or service under the plan, provide to the participant, 
 beneficiary, or enrollee (through mail or electronic means, as 
 requested by the participant, beneficiary, or enrollee) a 
 notification (in clear and understandable language and 
 utilizing substantially the same format as the advanced 
 explanation of benefits required by subsection

    (f) to enable 
 comparison) including the following:
 ``
        (A) Whether or not the provider or facility is a 
 participating provider or a participating facility with 
 respect to the plan or coverage with respect to the 
 furnishing of such item or service.
 ``
        (B) An itemized explanation of benefits that 
 includes the following:
 ``
            (i) A plain language description of each 
 item or service.
 ``
            (ii) All applicable billing codes for 
 each item or service, including modifiers, 
 using standard and commonly recognized billing 
 code sets that are clearly identified.
 ``
            (iii) The amount the plan or coverage is 
 responsible for paying for each item or 
 service.
 ``
            (iv) The amount of any cost-sharing for 
 which the participant, beneficiary, or enrollee 
 is responsible for each item or service (as of 
 the date of such notification).
 ``
            (v) The amount that the participant, 
 beneficiary, or enrollee has incurred toward 
 meeting the limit of the financial 
 responsibility (including with respect to 
 deductibles and out-of-pocket maximums) under 
 the plan or coverage (as of the date of such 
 notification).
 ``
            (vi) The site of each item or service.
 ``

    (2) Format.--If applicable, the notification described in 
 paragraph

    (1) may be provided in conjunction with, or as part 
 of, a notice of a claim determination or other communication 
 required by 

section 2719

    (a) (42 U.S.C. 300gg-19

    (a) ), or 
 regulations thereunder.
 ``

    (h) Regulations.--The Secretary shall implement this section 
through notice and comment rulemaking in accordance with 

section 553 of 
title 5, United States Code.''.

    (b) IRC Amendments.--

    (1) Emergency services.--

Section 9816

    (f)

    (1)
            (C) of the 
 Internal Revenue Code of 1986 is amended to read as follows:
 ``
            (C) A good faith estimate of the amount the plan 
 is responsible for paying for items and services 
 included in the estimate described in subparagraph
        (B) , 
 including a plain language description of each item or 
 service and all applicable billing codes for each item 
 or service, including modifiers, using standard and 
 commonly recognized billing code sets that are clearly 
 identified.''.

    (2) Explanation of benefits.--

Section 9816 of the Internal 
 Revenue Code of 1986 is amended by adding at the end the 
 following:
 ``

    (g) Explanation of Benefits.--
 ``

    (1) In general.--For plan years beginning on or after 
 January 1, 2026, each group health plan shall, within 45 days 
 of receiving any request for payment for an item or service 
 under the plan, provide to the participant or beneficiary 
 (through mail or electronic means, as requested by the 
 participant or beneficiary) a notification (in clear and 
 understandable language and utilizing substantially the same 
 format as the advanced explanation of benefits required by 
 subsection

    (f) to enable comparison) including the following:
 ``
        (A) Whether or not the provider or facility is a 
 participating provider or a participating facility with 
 respect to the plan with respect to the furnishing of 
 such item or service.
 ``
        (B) An itemized explanation of benefits that 
 includes the following:
 ``
            (i) A plain language description of each 
 item or service.
 ``
            (ii) All applicable billing codes for 
 each item or service, including modifiers, 
 using standard and commonly recognized billing 
 code sets that are clearly identified.
 ``
            (iii) The amount the plan is responsible 
 for paying for each item or service.
 ``
            (iv) The amount of any cost-sharing for 
 which the participant or beneficiary is 
 responsible for each item or service (as of the 
 date of such notification).
 ``
            (v) The amount that the participant or 
 beneficiary has incurred toward meeting the 
 limit of the financial responsibility 
 (including with respect to deductibles and out-
 of-pocket maximums) under the plan (as of the 
 date of such notification).
 ``
            (vi) The site of each item or service.
 ``

    (2) Format.--If applicable, the notification described in 
 paragraph

    (1) may be provided in conjunction with, or as part 
 of, a notice of a claim determination or other communication 
 required by 

section 503 of the Employee Retirement Income 
 Security Act of 1974 or regulations thereunder.
 ``

    (h) Regulations.--The Secretary shall implement this section 
through notice and comment rulemaking in accordance with 

section 553 of 
title 5, United States Code.''.
            (c) ERISA Amendments.--

    (1) Emergency services.--

Section 716

    (f)

    (1)
            (C) of the 
 Employee Retirement Income Security Act of 1974 (29 U.S.C. 
 1185e

    (f)

    (1)
            (C) ) is amended to read as follows:
 ``
            (C) A good faith estimate of the amount the 
 health plan is responsible for paying for items and 
 services included in the estimate described in 
 subparagraph
        (B) , including a plain language 
 description of each item or service and all applicable 
 billing codes for each item or service, including 
 modifiers, using standard and commonly recognized 
 billing code sets that are clearly identified.''.

    (2) Explanation of benefits.--

Section 716 of the Employee 
 Retirement Income Security Act of 1974 (29 U.S.C. 1185e) is 
 amended by adding at the end the following:
 ``

    (g) Explanation of Benefits.--
 ``

    (1) In general.--For plan years beginning on or after 
 January 1, 2026, each group health plan or health insurance 
 issuer offering group health insurance coverage shall, within 
 45 days of receiving any request for payment for an item or 
 service under the plan, provide to the participant or 
 beneficiary (through mail or electronic means, as requested by 
 the participant or beneficiary) a notification (in clear and 
 understandable language and utilizing substantially the same 
 format as the advanced explanation of benefits required by 
 subsection

    (f) to enable comparison) including the following:
 ``
        (A) Whether or not the provider or facility is a 
 participating provider or a participating facility with 
 respect to the plan or coverage with respect to the 
 furnishing of such item or service.
 ``
        (B) An itemized explanation of benefits that 
 includes the following:
 ``
            (i) A plain language description of each 
 item or service.
 ``
            (ii) All applicable billing codes for 
 each item or service, including modifiers, 
 using standard and commonly recognized billing 
 code sets that are clearly identified.
 ``
            (iii) The amount the plan or coverage is 
 responsible for paying for each item or 
 service.
 ``
            (iv) The amount of any cost-sharing for 
 which the participant or beneficiary is 
 responsible for each item or service (as of the 
 date of such notification).
 ``
            (v) The amount that the participant or 
 beneficiary has incurred toward meeting the 
 limit of the financial responsibility 
 (including with respect to deductibles and out-
 of-pocket maximums) under the plan or coverage 
 (as of the date of such notification).
 ``
            (vi) The site of each item or service.
 ``

    (2) Format.--If applicable, the notification described in 
 paragraph

    (1) may be provided in conjunction with, or as part 
 of, a notice of a claim determination or other communication 
 required by 

section 503 or regulations thereunder.
 ``

    (h) Regulations.--The Secretary shall implement this section 
through notice and comment rulemaking in accordance with 

section 553 of 
title 5, United States Code.''.

SEC. 11. PROVISION OF ITEMIZED BILLS.

 Part E of title XXVII of the Public Health Service Act (42 U.S.C. 
300gg-131 et seq.) is amended by adding at the end the following:

``

SEC. 2799B-10. PROVIDER REQUIREMENTS FOR ITEMIZED BILLS.

 ``

    (a) Requirements.--
 ``

    (1) Itemized bill and other information required.--
 ``
        (A) In general.--A health care provider or health 
 care facility that requests payment from an individual 
 after providing a health care item or service to the 
 patient shall include with such request a written, 
 itemized bill of the cost of each reasonably expected 
 item or service the health care provider or health care 
 facility provided to the individual, including 
 telehealth visits or visits by other electronic means. 
 The health care provider or health care facility shall 
 provide the itemized bill not later than 30 days after 
 the health care provider or health care facility 
 received a final payment on the provided service or 
 supply from a third party.
 ``
        (B) Required information.--For each item or 
 service provided by the health care provider or 
 facility or for which the health care provider or 
 facility is billing the individual, the itemized bill 
 must include--
 ``
            (i) a plain language description of each 
 distinct health care item or service;
 ``
            (ii) all applicable billing codes for 
 each distinct health care item or service, 
 including modifiers, using standard and 
 commonly recognized billing code sets that are 
 clearly identified;
 ``
            (iii) the price and billed amount, if 
 different, of each distinct health care item or 
 service or if the provider or facility is 
 offering binding, all-in prices for bundled 
 items and services, the total binding price for 
 bundled items and services and billed amount;
 ``
            (iv) any payments made to the health care 
 provider or health care facility by or on 
 behalf of the individual (including payments by 
 any health plan or insurance) for any health 
 care item or service covered in the itemized 
 bill;
 ``
            (v) information about the availability of 
 language-assistance services for individuals 
 with limited English proficiency

    (LEP) ;
 ``
            (vi) the identification of an office or 
 individual at the health care provider or 
 health care facility, including phone number 
 and email address, that shall be able to 
 discuss the specific details of the itemized 
 statement and be authorized to make appropriate 
 changes thereto; and
 ``
            (vii) information about the health care 
 provider's or health care facility's charity 
 care policies and instructions on how to apply 
 for charity care.
 ``

    (2) Collections actions.--
 ``
        (A) In general.--A health care provider or health 
 care facility shall not take any collections actions 
 against an individual--
 ``
            (i) for any provided health care item or 
 service unless the health care provider or 
 health care facility has complied with 
 paragraph

    (1) ; or
 ``
            (ii) with respect to any items or 
 services for which the amount appearing on an 
 itemized bill described above in paragraph

    (1) exceeds the amount disclosed pursuant to 
 Federal health care price transparency 
 regulations, including part 180 of title 45, 
 Code of Federal Regulations, or provided in a 
 good faith estimate that complies with 

section 2799B-6 of this Act and 

section 149.610 of 
 title 45, Code of Federal Regulations, or 
 another good faith estimate provided by a 
 health care entity covered under this section 
 but not otherwise covered under such 

section 2799B-6 unless the provider or facility 
 documents that the additional items or services 
 were medically necessary due to unforeseen 
 complications or a patient-initiated change, 
 and could not reasonably have been anticipated.
 ``
        (B) Burden of proof.--The burden of proof under 
 subparagraph
        (A)
            (ii) shall rest with the provider, and 
 absent the documentation described in such 
 subparagraph, the good faith estimate shall be binding.
 ``

    (b) Failure To Comply.--
 ``

    (1) Penalties.--The Secretary shall impose penalties on 
 any health care provider or health care facility that fails to 
 comply with the requirements of this section in an amount not 
 to exceed $10,000 for each instance of failure to comply.
 ``

    (2) Presumption in favor of individual.--If a health care 
 provider or health care facility fails to comply with the 
 requirements of this section, the presumption shall be that 
 charges were substantially in excess of the good faith estimate 
 (as set forth in 

section 2799B-6) for the purpose of any 
 patient-provider dispute, including in accordance with 

section 2799B-7 and regulations promulgated thereunder.
 ``
            (c) Regulations.--The Secretary shall implement this section 
through notice and comment rulemaking in accordance with 

section 553 of 
title 5, United States Code.''.
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