[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2691 Introduced in House (IH)]
<DOC>
118th CONGRESS
1st Session
H. R. 2691
To promote hospital and insurer price transparency.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
April 18, 2023
Mrs. Rodgers of Washington (for herself and Mr. Pallone) introduced the
following bill; which was referred to the Committee on Energy and
Commerce
_______________________________________________________________________
A BILL
To promote 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 ``Transparent Prices Required to
Inform Consumer and Employers Act'' or the ``Transparent PRICE Act''.
SEC. 2. PRICE TRANSPARENCY REQUIREMENTS.
(a) In General.--Section 2718(e) of the Public Health Service Act
(42 U.S.C. 300gg-18(e)) is amended--
(1) by striking ``Each hospital'' and inserting the
following:
``(1) In general.--Each hospital'';
(2) by inserting ``, in plain language without subscription
and free of charge, in a consumer-friendly, machine-readable
format,'' after ``a list''; and
(3) by adding at the end the following: ``Beginning January
1, 2024, each hospital shall include in its list of standard
charges, along with such additional information as the
Secretary may require with respect to such charges for purposes
of promoting public awareness of hospital pricing in advance of
receiving a hospital item or service, as applicable, the
following:
``(A) A description of each item or service
provided by the hospital, accompanied by, as
applicable, the Current Procedural Terminology (CPT)
code, the Healthcare Common Procedure Coding System
(HCPCS) code, the Diagnosis Related Group (DRG), the
National Drug Code (NDC), or other payer identifier
used or approved by the Centers for Medicare & Medicaid
Services.
``(B) The gross charge, expressed as a dollar
amount, for each such item or service, when provided
in, as applicable, the hospital inpatient setting and
outpatient department setting.
``(C) Any current payer-specific negotiated
charges, clearly associated with the name of the third
party payer and plan and expressed as a dollar amount,
that applies to each item or service when provided in,
as applicable, the hospital inpatient setting and
outpatient department setting.
``(D) The discounted cash price, expressed as a
dollar amount, for each such item or service when
provided in, as applicable, the hospital inpatient
setting and outpatient department setting. If the
discounted cash price is a percentage of another value
provided, the calculated value must be entered as a
dollar amount. If the discounted cash price equates to
the gross charge, the gross charge shall be re-entered
to indicate that no cash discount is available.
``(E) The average negotiated rate and acquisition
cost paid by the hospital for each drug or biological
product--
``(i) for which payment would be made under
part B of title XVIII of the Social Security
Act if the individual administered such drug or
biological product were enrolled under such
part B; and
``(ii) that is administered by the hospital
or an entity with a direct financial
relationship to the hospital during the
previous year,
which, in the case of such a drug or biological product
that is first administered in the hospital during the
previous 12-month period, shall be included in such
list of standard charges beginning not later than 30
days after the date of such first administration.
``(2) Delivery methods and use.--
``(A) In general.--Each hospital shall make public
the standard charges described in paragraph (1) for as
many of the 70 Centers for Medicare & Medicaid
Services-specified shoppable services that are provided
by the hospital, and as many additional hospital-
selected shoppable services as may be necessary for a
combined total of at least 300 shoppable services,
including the rate at which a hospital provides and
bills for that shoppable service. If a hospital does
not provide 300 shoppable services in accordance with
the previous sentence, the hospital shall make public
the information specified under paragraph (1) for as
many shoppable services as it provides.
``(B) Determination by cms.--With respect to a year
before 2025, a hospital shall be deemed by the Centers
for Medicare & Medicaid Services to meet the
requirements of subparagraph (A) if the hospital
maintains an internet-based price estimator tool that
meets the following requirements:
``(i) The tool provides estimates for as
many of the 70 specified shoppable services
that are provided by the hospital, and as many
additional hospital-selected shoppable services
as may be necessary for a combined total of at
least 300 shoppable services.
``(ii) The tool allows health care
consumers to, at the time they use the tool,
obtain an estimate of the amount they will be
obligated to pay the hospital for the shoppable
service.
``(iii) The tool is prominently displayed
on the hospital's website and easily accessible
to the public, without subscription, fee, or
having to submit personal identifying
information (PII), and searchable by service
description, billing code, and payer.
``(3) Uniform method and format.--Not later than January 1,
2025, the Secretary shall implement a standard, uniform method
and format for hospitals to use in order to satisfy the
requirements of this subsection for disclosing directly to the
public charge and price information. Such method and format may
be similar to any template established by the Centers for
Medicare & Medicaid Services as of the date of the enactment of
this paragraph for reporting such information under this
subsection and shall meet such standards as determined
appropriate by the Secretary.
``(4) Monitoring of pricing information.--The Secretary, in
consultation with the Inspector General of the Department of
Health and Human Services, shall, through notice and comment
rulemaking, establish a process to regularly monitor the
accuracy and validity of pricing information displayed by each
hospital pursuant to paragraph (1).
``(5) Definitions.--Notwithstanding any other provision of
law, for the purpose of paragraphs (1) and (2):
``(A) De-identified maximum negotiated charge.--The
term `de-identified maximum negotiated charge' means
the highest charge that a hospital has negotiated with
all third party payers for an item or service.
``(B) De-identified minimum negotiated charge.--The
term `de-identified minimum negotiated charge' means
the lowest charge that a hospital has negotiated with
all third party payers for an item or service.
``(C) Discounted cash price.--The term `discounted
cash price' means the charge that applies to an
individual who pays cash, or cash equivalent, for a
hospital item or service. Hospitals that do not offer
self-pay discounts may display the hospital's
undiscounted gross charges as found in the hospital
chargemaster.
``(D) Gross charge.--The term `gross charge' means
the charge for an individual item or service that is
reflected on a hospital's chargemaster, absent any
discounts.
``(E) Payer-specific negotiated charge.--The term
`payer-specific negotiated charge' means the charge
that a hospital has negotiated with a third party payer
for an item or service.
``(F) Shoppable service.--The term `shoppable
service' means a service that can be scheduled by a
health care consumer in advance.
``(G) Standard charges.--The term `standard
charges' means the regular rate established by the
hospital for an item or service, including both
individual items and services and service packages,
provided to a specific group of paying patients,
including the gross charge, the payer-specific
negotiated charge, the discounted cash price, the de-
identified minimum negotiated charge, the de-identified
maximum negotiated charge, and other rates determined
by the Secretary.
``(H) Third party payer.--The term `third party
payer' means an entity that is, by statute, contract,
or agreement, legally responsible for payment of a
claim for a health care item or service.
``(6) Enforcement.--
``(A) In general.--In the case of a hospital that
fails to provide the information required by this
subsection--
``(i) the Secretary shall notify such
hospital of such failure not later than 30 days
after the date on which the Secretary
determines such failure exists; and
``(ii) not later than 90 days after the
date of such notification, the hospital shall
complete 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 subsection (b)(3) or another provision of
law, a hospital that has received a
notification under subparagraph (A)(i) and
fails to satisfy the requirement under
subparagraph (A)(ii) or otherwise comply with
the requirements of this subsection not later
than 90 days after such notification, shall be
subject to a civil monetary penalty of an
amount--
``(I) in the case the hospital
provides not more than 30 beds (as
determined under section
180.90(c)(2)(ii)(D) of title 45, Code
of Federal Regulations, as in effect on
the date of the enactment of this
paragraph), not to exceed $300 per day
that the violation is ongoing as
determined by the Secretary; and
``(II) in the case the hospital
provides more than 30 beds (as so
determined), equal to--
``(aa) subject to item
(bb), $10 per bed per day that
the violation is ongoing as
determined by the Secretary,
but for violations occurring
before January 1, 2024, not to
exceed $5,500 per each such
day; or
``(bb) in the case such
hospital has failed to satisfy
the requirement under
subparagraph (A)(ii) or
otherwise comply with the
requirements of this subsection
for any continuous 1-year
period beginning on or after
January 1, 2024, and the amount
otherwise imposed under item
(aa) for such failure for such
period would be less than
$5,000,000, an amount not less
than $5,000,000.
``(ii) Increase authority.--In applying
this subparagraph with respect to violations
occurring in 2025 or a subsequent year, the
Secretary may through notice and comment
rulemaking increase any dollar amount applied
under this subparagraph by an amount specified
by the Secretary.
``(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 clause (i)
in the same manner as such provisions apply to
a civil monetary penalty imposed under
subsection (a) of such section.''.
(b) Publication of List of Hospitals.--
(1) List of hospitals.--Beginning not later than 90 days
after the date of enactment of this Act, the Secretary of
Health and Human Services (referred to in this section as the
``Secretary'') shall establish and maintain a publicly
available list, on the website of the Centers for Medicare &
Medicaid Services and updated in real time, of--
(A) each hospital that--
(i) is not in compliance with the hospital
price transparency rule implementing section
2718(e) of the Public Health Service Act (42
U.S.C. 300gg-18(e)), and that, with respect to
such noncompliance--
(I) has been issued a civil
monetary penalty;
(II) has received a warning notice;
or
(III) has received a request for a
corrective action plan; or
(ii) has received any written communication
by the Secretary regarding potential
noncompliance with such hospital price
transparency rule; and
(B) each hospital that is in compliance with
respect to such hospital price transparency rule and
has not received any written communication described in
paragraph (1)(B).
(2) Foia requests.--Any penalty, notice, request, or other
communication described in subsection (a) shall be subject to
public disclosure, in full and without redaction, under section
552 of title 21, United States Code, notwithstanding any
exemptions or exclusions otherwise available under such section
552.
(3) Reports to congress.--Not later than 1 year after the
date of enactment of this Act and each year thereafter, the
Secretary of Health and Human Services shall submit to
Congress, and make publicly available, a report that contains
information regarding complaints of alleged violations of law
and enforcement activities by the Secretary under the hospital
price transparency rule implementing section 2718(e) of the
Public Health Service Act (42 U.S.C. 300gg-18(e)). Such report
shall be made available to the public on the website of the
Centers for Medicare & Medicaid Services. Each such report
shall include, with respect to the year involved--
(A) the number of compliance and enforcement
inquiries opened by the Secretary pursuant to such
section;
(B) the number of notices of noncompliance issued
by the Secretary based on such inquiries;
(C) the identity of each hospital entity that
received a notice of noncompliance and the nature of
the failure giving rise to the Secretary's
determination of noncompliance;
(D) the amount of civil monetary penalty assessed
against the hospital entity;
(E) whether the hospital entity subsequently
corrected the noncompliance; and
(F) an analysis of factors contributing to
increasing health care costs.
(4) Gao report.--Not later than 1 year after the date of
enactment of this Act, the Comptroller General of the United
States shall submit to the Committee on Energy and Commerce of
the House of Representatives and the Committee on Health,
Education, Labor, and Pensions and the Committee on Finance of
the Senate a report on the compliance and enforcement with the
hospital price transparency rule implementing section 2718(e)
of the Public Health Service Act (42 U.S.C. 300gg-18(e)). The
report shall include recommendations related to--
(A) improving price transparency to patients,
employers, and the public; and
(B) increased civil monetary penalty amounts to
ensure compliance.
(5) Request for information.--Not later than January 1,
2025, the Secretary of Health and Human Services shall issue a
public request for information as to the best method through
which hospitals may be required to publish quality data (such
as data required to be reported under the Medicare Hospital
Compare program) alongside data required to be reported under
section 2718(e) of the Public Health Service Act (42 U.S.C.
300gg-18(e)).
SEC. 3. STRENGTHENING HEALTH INSURANCE TRANSPARENCY REQUIREMENTS.
(a) Cost Sharing Transparency.--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 disclosure
(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 an item or
service for which benefits are available under
a health plan 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
amount the plan will recognize as
payment 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); and
``(V) provides that such a request
may be made with respect to an item or
service through use of the billing code
for such item or service or through use
of a descriptive term for such item or
service.
The Secretary may require such tool, as a
condition of complying with subclause (V), to
link multiple billing codes to a single
descriptive term if the Secretary determines
that the billing codes to be so linked
correspond to items and services with no more
than a de minimis difference in patient
experience in receiving such items and services
and cost sharing imposed under such plan for
such items and services.''.
(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, 2024, and every 3 months 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 (other than a drug) for which
benefits are available under such plan,
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 that, during the
1-year period ending on such date,
submitted fewer than 10 claims for such
item or service to such plan.
``(II) With respect to each drug
(identified by national drug code) for
which benefits are available under such
plan, the average amount paid by such
plan (net of rebates, discounts, and
price concessions) for such drug
dispensed or administered during the
90-day period 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, during such
period, submitted fewer than 20 claims
for such drug to such plan.
``(III) With respect to each item
or service for which benefits are
available under such plan, the amount
billed, and the amount recognized by
the plan, for each such item or service
furnished during the 1-year period
ending on such date by a 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 amounts billed by, and amounts
recognized by a plan with respect to, a
provider that, during such period,
submitted fewer than 10 claims for such
item or service to such plan.
``(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 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. Such requirements
shall ensure that 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.
``(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(a)(3) 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.''.
(c) Reports.--
(1) Compliance.--Not later than January 1, 2025, the
Comptroller General of the United States shall submit to
Congress a report containing--
(A) an analysis of health plan compliance with the
amendments made by this section;
(B) an analysis of enforcement of such amendments
by the Secretaries of Health and Human Services, Labor,
and the Treasury;
(C) recommendations relating to improving such
enforcement; and
(D) recommendations relating to improving public
disclosure, and public awareness, of information
required to be made available by such plans pursuant to
such amendments.
(2) Prices.--Not later than January 1, 2028, the
Comptroller General of the United States shall submit to
Congress a report containing an assessment of differences in
negotiated prices (and any trends in such prices) in the
private market between--
(A) rural and urban areas;
(B) the individual, small group, and large group
markets;
(C) consolidated and nonconsolidated health care
provider areas (as specified by the Secretary);
(D) nonprofit and for-profit hospitals;
(E) nonprofit and for-profit insurers; and
(F) insurers serving local or regional areas and
insurers serving multistate or national areas.
(d) Effective Date.--The amendments made by subsection (a) shall
apply beginning January 1, 2024.
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