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Lower Costs, More Transparency Act

Floor Speech

By: Cathy Rodgers

Date: Dec. 11, 2023

Location: Washington, DC

BREAK IN TRANSCRIPT

Mrs. RODGERS of Washington. Mr. Speaker, I move to suspend the rules and pass the bill (H.R. 5378) to promote price transparency in the health care sector, and for other purposes, as amended.

The Clerk read the title of the bill.

The text of the bill is as follows: H.R. 5378

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 ``Lower Costs, More Transparency Act''. SEC. 2. TABLE OF CONTENTS.

The table of contents of this Act is as follows: Sec. 1. Short title. Sec. 2. Table of contents. TITLE I--IMPROVING HEALTH CARE TRANSPARENCY Sec. 101. Hospital price transparency. Sec. 102. Clinical diagnostic laboratory test price transparency. Sec. 103. Imaging price transparency. Sec. 104. Ambulatory surgical center price transparency. Sec. 105. Health coverage price transparency. Sec. 106. Pharmacy benefits price transparency. Sec. 107. Reports on health care transparency tools and data. Sec. 108. Report on integration in Medicare. Sec. 109. Advisory Committee. Sec. 110. Report on impact of Medicare regulations on provider and payer consolidation. Sec. 111. Implementation funding. TITLE II--REDUCING HEALTH CARE COSTS FOR PATIENTS Sec. 201. Increasing transparency in generic drug applications. Sec. 202. Improving transparency and preventing the use of abusive spread pricing and related practices in Medicaid. Sec. 203. Parity in Medicare payments for hospital outpatient department services furnished off-campus. Sec. 204. Requiring a separate identification number and an attestation for each off-campus outpatient department of a provider. TITLE III--SUPPORTING PATIENTS, HEALTH CARE WORKERS, COMMUNITY HEALTH CENTERS, AND HOSPITALS Sec. 301. Extension for community health centers, the national health service corps, and teaching health centers that operate GME programs. Sec. 302. Extension of special diabetes programs. Sec. 303. Delaying certain disproportionate share payment cuts. Sec. 304. Medicaid improvement fund. TITLE IV--INCREASING ACCESS TO QUALITY HEALTH DATA AND LOWERING HIDDEN FEES Sec. 401. Increasing Plan Fiduciaries' Access to Health Data. Sec. 402. Hidden Fees Disclosure Requirements. Sec. 403. Prescription drug price information requirement. Sec. 404. Implementation funding. TITLE I--IMPROVING HEALTH CARE TRANSPARENCY SEC. 101. HOSPITAL PRICE TRANSPARENCY.

(a) Medicare.--Part E of title XVIII of the Social Security Act (42 U.S.C. 1395x et seq.) is amended by adding at the end the following new section: ``SEC. 1899C. HOSPITAL PRICE TRANSPARENCY.

``(a) Transparency Requirement.--

``(1) In general.--Beginning January 1, 2026, each specified hospital that receives payment under this title for furnishing items and services shall comply with the price transparency requirement described in paragraph (2).

``(2) Requirement described.--

``(A) In general.--For purposes of paragraph (1), the price transparency requirement described in this paragraph is, with respect to a specified hospital, that such hospital, in accordance with a method and format established by the Secretary under subparagraph (C), compile and make public (without subscription and free of charge) for each year--

``(i) all of the hospital's standard charges (including the information described in subparagraph (B)) for each item and service furnished by such hospital;

``(ii) information in a consumer-friendly format (as specified by the Secretary)--

``(I) on the hospital's prices (including the information described in subparagraph (B)) for 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; and

``(II) that includes, 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; and

``(iii) an attestation that all information made public pursuant to this subparagraph is complete and accurate.

``(B) Information described.--For purposes of subparagraph (A), the information described in this subparagraph is, with respect to standard charges and prices, as applicable, made public by a specified hospital, the following:

``(i) A plain language description of each item or service, accompanied by, as applicable, the Healthcare Common Procedure Coding System code, the diagnosis-related group, the national drug code, or other identifier used or approved by the Centers for Medicare & Medicaid Services.

``(ii) The gross charge, as applicable, 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, as applicable, 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 median cash price charged by the hospital to 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 hospital's charity care policy that includes, if applicable, any sliding scale payment structure employed for determining charges for a self-pay individual).

``(iv) The payer-specific negotiated charges, as applicable, clearly associated with the name of the third party payer and plan and expressed as a dollar amount, that apply to each such item or service when provided in, as applicable, the inpatient setting and outpatient department setting.

``(v) The de-identified maximum and minimum negotiated charges, as applicable, for each such item or service.

``(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 specified 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--

``(i) shall, 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 format (or a successor technology specified by the Secretary);

``(ii) may be similar to any template made available by the Centers for Medicare & Medicaid Services as of the date of the enactment of this subparagraph;

``(iii) shall meet such standards as determined appropriate by the Secretary in order to ensure the accessibility and usability of such charges and prices; and

``(iv) shall be updated as determined appropriate by the Secretary, in consultation with stakeholders.

``(3) 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. Such process shall ensure that each specified hospital's compliance with this subsection is reviewed not less frequently than once every 3 years.

``(4) Enforcement.--

``(A) In general.--In the case of a specified hospital that fails to comply with the requirements of this subsection--

``(i) 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 may include, as determined appropriate by the Secretary, a request for a corrective action plan to comply with such requirements); and

``(ii) in the case of a hospital that does not receive a request for a corrective action plan as part of a notification submitted by the Secretary under clause (i)--

``(I) the Secretary shall, not later than 45 days after such notification is sent, determine whether such hospital is in compliance with such requirements; and

``(II) if the Secretary determines under subclause (I) that such hospital is not in compliance with such requirements, the Secretary shall either--

``(aa) submit to such hospital a request for a corrective action plan to comply with such requirements; or

``(bb) if the Secretary determines that such hospital has not taken meaningful actions to come into compliance since such notification was sent, impose a civil monetary penalty in accordance with subparagraph (B).

``(B) Civil monetary penalty.--

``(i) In general.--Subject to clause (vii), in addition to any other enforcement actions or penalties that may apply under another provision of law, a specified hospital that has received a request for a corrective action plan under clause (i) or (ii) of subparagraph (A) and fails to comply with the requirements of this subsection by the date that is 45 days after such request is made, and a specified hospital with respect to which the Secretary has made a determination described in clause (ii)(II)(bb) of such subparagraph, 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 specified hospital with 30 or fewer beds, $300 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, $400 per day);

``(II) in the case of a specified 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 specified hospital with more than 100 beds but fewer than 201 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 specified hospital with more than 200 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 specified 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 specified 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 amounts specified in clause (iii)(II).

``(iii) Persistent noncompliance.--

``(I) In general.--In the case of a specified hospital (other than a specified hospital with 30 or fewer beds) 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 specified 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) Authority to waive or reduce penalty.--

``(I) In general.--Subject to subclause (II), the Secretary may waive any penalty, or reduce any penalty by not more than 75 percent, otherwise applicable under this subparagraph with respect to a specified hospital located in a rural or underserved area if the Secretary certifies that imposition of such penalty would result in an immediate threat to access to care for individuals in the service area of such hospital.

``(II) Limitation on application.--The Secretary may not elect to waive a penalty under subclause (I) with respect to a specified hospital more than once in a 6-year period and may not elect to reduce such a penalty with respect to such a hospital more than once in such a period. Nothing in the preceding sentence shall be construed as prohibiting the Secretary from both waiving and reducing a penalty with respect to a specified hospital during a 6-year period.

``(v) 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 hospitals requesting such assistance.

``(vi) 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.

``(vii) Nonduplication of certain penalties.--The Secretary may not subject a specified hospital to a civil monetary penalty under this subparagraph with respect to noncompliance with the provisions of this section for a period if the Secretary has imposed a civil monetary penalty on such hospital under section 2718(f) of the Public Health Service Act for failure to comply with the provisions of such section for such period.

``(C) Publication of hospital price transparency information.--Beginning on January 1, 2026, the Secretary shall make publicly available on the public website of the Centers for Medicare & Medicaid Services information with respect to compliance with the requirements of this subsection and enforcement activities undertaken by the Secretary under this subsection. Such information shall be updated in real time and include--

``(i) the number of reviews of compliance with this subsection undertaken by the Secretary;

``(ii) the number of notifications described in subparagraph (A)(i) sent by the Secretary;

``(iii) the identity of each specified hospital that was sent such a notification and a description of the nature of such hospital's noncompliance with this subsection;

``(iv) the amount of any civil monetary penalty imposed on such hospital under subparagraph (B);

``(v) whether such hospital subsequently came into compliance with this subsection;

``(vi) any waivers or reductions of penalties made pursuant to a certification by the Secretary under subparagraph (B)(iv), including--

``(I) the name of any specified hospital that received such a waiver or reduction;

``(II) the dollar amount of each such penalty so waived or reduced; and

``(III) the rationale for the granting of each such waiver or reduction; and

``(vii) any other information as determined by the Secretary.

``(b) Ensuring Accessibility Through Implementation.--In implementing the amendments made by this section, the Secretary of Health and Human Services shall through rulemaking ensure that a hospital submitting charges and information pursuant to such amendments takes reasonable steps (as specified by the Secretary) to ensure the accessibility of such charges and information to individuals with limited English proficiency. Such steps may include the hospital's provision of interpretation services or the hospital's provision of translations of charges and information.

``(c) Definitions.--For purposes of this section:

``(1) 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.

``(2) Federal health care program.--The term `Federal health care program' has the meaning given such term in section 1128B.

``(3) Gross charge.--The term `gross charge' means the charge for an individual item or service that is reflected on a specified hospital's or provider of service's or supplier's, as applicable, chargemaster, absent any discounts.

``(4) 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.

``(5) Payer-specific negotiated charge.--The term `payer- specific negotiated charge' means the charge that a specified hospital or provider of services or supplier, as applicable, has negotiated with a third party payer for an item or service.

``(6) 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.

``(7) Specified hospital.--The term `specified hospital' means a hospital (as defined in section 1861(e)), a critical access hospital (as defined in section 1861(mmm)(1)), or a rural emergency hospital (as defined in section 1861(kkk)).

``(8) 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.''.

(b) PHSA.--

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

``(f) Hospital Transparency Requirement.--

``(1) In general.--Beginning January 1, 2026, each hospital shall comply with the price transparency requirement described in paragraph (2).

``(2) Requirement described.--

``(A) In general.--For purposes of paragraph (1), the price transparency requirement described in this paragraph is, with respect to a hospital, that such hospital, in accordance with a method and format established by the Secretary under subparagraph (C), compile and make public (without subscription and free of charge) for each year--

``(i) all of the hospital's standard charges (including the information described in subparagraph (B)) for each item and service furnished by such hospital;

``(ii) information in a consumer-friendly format (as specified by the Secretary)--

``(iii) an attestation that all information made public pursuant to this subparagraph is complete and accurate.

``(i) A plain language description of each item or service, accompanied by, as applicable, the Healthcare Common Procedure Coding System code, the diagnosis-related group, the national drug code, current procedure terminology codes, or other identifier used or approved by the Centers for Medicare & Medicaid Services.

``(ii) The gross charge, as applicable, expressed as a dollar amount, for each such item or service, when provided in, as applicable, the inpatient setting and outpatient department setting.

``(v) The de-identified maximum and minimum negotiated charges, as applicable, for each such item or service.

``(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--

``(ii) may be similar to any template made available by the Centers for Medicare & Medicaid Services as of the date of the enactment of this subparagraph;

``(iii) shall meet such standards as determined appropriate by the Secretary in order to ensure the accessibility and usability of such charges and prices; and

``(iv) shall be updated as determined appropriate by the Secretary, in consultation with stakeholders.

``(3) 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. Such process shall ensure that each hospital's compliance with this subsection is reviewed not less frequently than once every 3 years.

``(4) Enforcement.--

``(A) In general.--In the case of a hospital that fails to comply with the requirements of this subsection--

``(ii) in the case of a hospital that does not receive a request for a corrective action plan as part of a notification submitted by the Secretary under clause (i)--

``(I) the Secretary shall, not later than 45 days after such notification is sent, determine whether such hospital is in compliance with such requirements; and

``(II) if the Secretary determines under subclause (I) that such hospital is not in compliance with such requirements, the Secretary shall either--

``(aa) submit to such hospital a request for a corrective action plan to comply with such requirements; or

``(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 clause (i) or (ii) of subparagraph (A) and fails to comply with the requirements of this subsection by the date that is 45 days after such request is made, and a hospital with respect to which the Secretary has made a determination described in clause (ii)(II)(bb) of such subparagraph, 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 (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, $400 per bed 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 201 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 200 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 amounts specified in clause (iii)(II).

``(iii) Persistent noncompliance.--

``(I) In general.--In the case of a hospital (other than a hospital with 30 or fewer beds) 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) Authority to waive or reduce penalty.--

``(I) In general.--Subject to subclause (II), the Secretary may waive any penalty, or reduce any penalty by not more than 75 percent, otherwise applicable under this subparagraph with respect to a hospital located in a rural or underserved area if the Secretary certifies that imposition of such penalty would result in an immediate threat to access to care for individuals in the service area of such hospital.

``(II) Limitation on application.--The Secretary may not elect to waive a penalty under subclause (I) with respect to a hospital more than once in a 6-year period and may not elect to reduce such a penalty with respect to such a hospital more than once in such a period. Nothing in the preceding sentence shall be construed as prohibiting the Secretary from both waiving and reducing a penalty with respect to a hospital during a 6-year period.

``(v) Provision of technical assistance.--The Secretary shall, to the extent practicable, provide technical assistance relating to compliance with the provisions of this section to hospitals requesting such assistance.

``(vii) Nonduplication of penalties.--The Secretary may not subject a hospital to a civil monetary penalty under this subparagraph with respect to noncompliance with the provisions of this subsection for a period if the Secretary has imposed a civil monetary penalty on such hospital under section 1899C of the Social Security Act for failure to comply with the provisions of such section for such period.

``(i) the number of reviews of compliance with this subsection undertaken by the Secretary;

``(ii) the number of notifications described in subparagraph (A)(i) sent by the Secretary;

``(iii) the identity of each hospital that was sent such a notification and a description of the nature of such hospital's noncompliance with this subsection;

``(iv) the amount of any civil monetary penalty imposed on such hospital under subparagraph (B);

``(v) whether such hospital subsequently came into compliance with this subsection;

``(vi) any waivers or reductions of penalties made pursuant to a certification by the Secretary under subparagraph (B)(iv), including--

``(I) the name of any hospital that received such a waiver or reduction;

``(II) the dollar amount of each such penalty so waived or reduced; and

``(III) the rationale for the granting of each such waiver or reduction; and

``(vii) any other information as determined by the Secretary.

``(5) Ensuring accessibility through implementation.--In implementing the amendments made by this section, the Secretary of Health and Human Services shall through rulemaking ensure that a hospital submitting charges and information pursuant to such amendments takes reasonable steps (as specified by the Secretary) to ensure the accessibility of such charges and information to individuals with limited English proficiency. Such steps may include the hospital's provision of interpretation services or the hospital's provision of translations of charges and information.

``(6) Definitions.--For purposes of this subsection:

``(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 hospital-furnished item or service.

``(B) Federal health care program.--The term `Federal health care program' has the meaning given such term in section 1128B of the Social Security Act.

``(C) 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.

``(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.''.

(2) Conforming amendments.--Section 2718 of the Public Health Service Act (42 U.S.C. 300gg-18) is amended--

(A) in subsection (b)(3), by inserting ``(other than the provisions of subsection (f))'' after ``this section''; and

(B) in subsection (e), by adding at the end the following new sentence: ``The preceding provisions of this subsection shall not apply beginning on January 1, 2026.''.

(3) Effective date.--The amendments made by this subsection shall apply beginning January 1, 2026.

(c) Accessibility Through Implementation.--In implementing the amendments made by this section, the Secretary of Health and Human Services shall through rulemaking ensure that a hospital submitting charges and information pursuant to such amendments takes reasonable steps (as specified by the Secretary) to ensure the accessibility of such charges and information to individuals with limited English proficiency. Such steps may include the hospital's provision of interpretation services or the hospital's provision of translations of charges and information. SEC. 102. CLINICAL DIAGNOSTIC LABORATORY TEST PRICE TRANSPARENCY.

Section 1846 of the Social Security Act (42 U.S.C. 1395w-2) is amended--

(1) in the header, by inserting ``and additional requirements'' after ``sanctions''; and

(2) by adding at the end the following new subsection:

``(c) Price Transparency Requirement.--

``(1) In general.--Beginning January 1, 2026, any applicable laboratory that receives payment under this title for furnishing any specified clinical diagnostic laboratory test under this title 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 annually.

``(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) The discounted cash price for such test (or, if no such price exists, the gross charge for such test).

``(B) The deidentified minimum payer-specific negotiated charge between such laboratory and any third party payer for such test.

``(C) The deidentified maximum payer-specific negotiated charge between such laboratory and any third party payer for such test.

``(3) Uniform method and format.--Not later than January 1, 2026, 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--

``(A) may be similar to any template made available by the Centers for Medicare & Medicaid Services (as described in section 1899C(a)(2)(C)(ii));

``(B) shall meet such standards as determined appropriate by the Secretary in order to ensure the accessibility and usability of such information; and

``(C) shall 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 (as applicable) for any ancillary item or service (such as specimen collection services) that would normally 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 (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 2027 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 (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' has the meaning given such term in section 414.502, 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 section 1899C or section 2718(f) of the Public Health Service Act.

``(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 section 1899C(a)(2)(A)(ii)(I)), 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.''. SEC. 103. IMAGING PRICE TRANSPARENCY.

Section 1899C of the Social Security Act, as added by section 101, is amended--

(1) by redesignating subsection (b) as subsection (c);

(2) by inserting after subsection (a) the following new subsection:

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

``(1) In general.--Beginning January 1, 2028, each provider of services and supplier that receives payment under this title for furnishing 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 section 1899C or section 2718(f) of the Public Health Service Act, 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) The discounted cash price for such service (or, if no such price exists, the gross charge for such service).

``(B) If required by the Secretary, the deidentified minimum payer-specific negotiated charge for such service and the deidentified maximum payer-specific negotiated charge for such service.

``(3) Uniform method and format.--Not later than January 1, 2028, 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--

``(A) may be similar to any template made available by the Centers for Medicare & Medicaid Services (as described in section 1899C(a)(2)(C)(ii));

``(B) shall meet such standards as determined appropriate by the Secretary in order to ensure the accessibility and usability of such information; and

``(C) shall 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 2029 or a subsequent year, the Secretary may through notice and comment rulemaking increase the amount of the civil monetary penalty under subparagraph (A)(iii).

``(D) Authority to waive or reduce penalty.--

``(i) In general.--Subject to clause (ii), the Secretary may waive or reduce any penalty otherwise applicable with respect to a provider of services or supplier under this subparagraph if the Secretary certifies that imposition of such penalty would result in an immediate threat to access to care for individuals in the service area of such provider or supplier.

``(ii) Limitation.--The Secretary may not elect to waive or reduce a penalty under clause (i) with respect to a specific provider of services or supplier more than 3 times.

``(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.''; and

(3) in subsection (c), as so redesignated by paragraph (1)--

(A) by redesignating paragraph (8) as paragraph (9); and

(B) by inserting after paragraph (7) the following new paragraph:

``(8) Specified imaging service.--the term `specified imaging service' means an imaging service that is a Centers for Medicare & Medicaid Services-specified shoppable service (as described in subsection (a)(2)(A)(ii)(I)).''. SEC. 104. AMBULATORY SURGICAL CENTER PRICE TRANSPARENCY.

Section 1834 of the Social Security Act (42 U.S.C. 1395m) is amended by adding at the end the following new subsection:

``(aa) Ambulatory Surgical Center Price Transparency.--

``(1) In general.--Beginning January 1, 2026, each ambulatory surgical center that receives payment under this title for furnishing items and services shall comply with the price transparency requirement described in paragraph (2).

``(2) Requirement described.--

``(A) In general.--For purposes of paragraph (1), the price transparency requirement described in this subsection is, with respect to an ambulatory surgical center, that such surgical center in accordance with a method and format established by the Secretary under subparagraph (C), compile and make public (without subscription and free of charge), for each year--

``(i) all 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 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 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 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 (as applicable) made public by an ambulatory surgical center, the following:

``(ii) The gross charge, as applicable, expressed as a dollar amount, for each such item or service.

``(iii) The discounted cash price, as applicable, 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 median cash price charged to self-pay individuals for such item or service for the previous three years, expressed as a dollar amount).

``(iv) The 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 such item or service.

``(v) The de-identified maximum and minimum negotiated charges, as applicable, for each such item or service.

``(C) Uniform method and format.--Not later than January 1, 2026, the Secretary shall establish a standard, uniform method and format for ambulatory surgical centers to use in making public standard charges and a standard, uniform method and format for such centers to use in making public prices pursuant to subparagraph (A). Any such method and format--

``(i) shall, 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 (or successor technology);

``(ii) may be similar to any template made available by the Centers for Medicare & Medicaid Services as of the date of the enactment of this paragraph;

``(iii) shall meet such standards as determined appropriate by the Secretary in order to ensure the accessibility and usability of such charges and prices; and

``(iv) shall be updated as determined appropriate by the Secretary, in consultation with stakeholders.

``(3) 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. Such process shall ensure that each ambulatory surgical center's compliance with this subsection is reviewed not less frequently than once every 3 years.

``(4) Enforcement.--

``(A) In general.--In the case of an 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.--In addition to any other enforcement actions or penalties that may apply under another provision of law, an 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 subsequent day 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 an ambulatory surgical center under clause (i).

``(iii) 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.

``(iv) Authority to waive or reduce penalty.--

``(I) In general.--Subject to subclause (II), the Secretary may waive any penalty, or reduce any penalty by not more than 75 percent, otherwise applicable under this subparagraph with respect to an ambulatory surgical center located in a rural or underserved area if the Secretary certifies that imposition of such penalty would result in an immediate threat to access to care for individuals in the service area of such surgical center.

``(II) Limitation on application.--The Secretary may not elect to waive a penalty under subclause (I) with respect to an ambulatory surgical center more than once in a 6-year period and may not elect to reduce such a penalty with respect to such a surgical center more than once in such a period. Nothing in the preceding sentence shall be construed as prohibiting the Secretary from both waiving and reducing a penalty with respect to an ambulatory surgical center during a 6-year period.

``(5) 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) Federal health care program.--The term `Federal health care program' has the meaning given such term in section 1128B.

``(C) Gross charge.--The term `gross charge' means the charge for an individual item or service that is reflected on an ambulatory surgical center's chargemaster, absent any discounts.

``(D) 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.

``(E) Payer-specific negotiated charge.--The term `payer- specific negotiated charge' means the charge that an ambulatory surgical center 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 and includes all ancillary items and services customarily furnished as part of such service.

``(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.''. SEC. 105. HEALTH COVERAGE PRICE TRANSPARENCY.

(a) Price Transparency Requirements.--

(1) IRC.--

(A) In general.--Section 9819 of the Internal Revenue Code of 1986 is amended to read as follows: ``SEC. 9819. TRANSPARENCY IN COVERAGE.

``(a) Cost-sharing Transparency.--

``(1) In general.--For plan years beginning on or after January 1, 2026, a group health plan shall permit a participant or beneficiary to learn the amount of cost- sharing (including deductibles, copayments, and coinsurance) under the participant or beneficiary's plan that the participant or beneficiary would be responsible for paying with respect to the furnishing of a specific item or service by a provider in a timely manner upon the request of the participant or beneficiary. At a minimum, such information shall include the information specified in paragraph (2) and shall be made available to such participant or beneficiary through a self-service tool that meets the requirements of paragraph (3) or, at the option of such participant or beneficiary, through a paper disclosure or phone or other electronic disclosure (as selected by such participant or beneficiary and provided at no cost to such participant or beneficiary) that meets such requirements as the Secretary may specify.

``(2) Specified information.--For purposes of paragraph (1), the information specified in this paragraph is, with respect to an item or service for which benefits are available under a group health plan furnished by a health care provider to a participant or beneficiary of such plan, the following:

``(A) If such provider is a participating provider with respect to such item or service, the in-network rate (as defined in subsection (c)) for such item or service.

``(B) If such provider is not a participating provider with respect to such item or service, the maximum allowed amount or other dollar amount that such plan or coverage will recognize as payment for such item or service, along with a notice that such participant or beneficiary may be liable for additional charges.

``(C) The estimated amount of cost sharing (including deductibles, copayments, and coinsurance) that the participant or beneficiary will incur for such item or service (which, in the case such item or service is to be furnished by a provider described in subparagraph (B), shall be calculated using the maximum allowed amount or other dollar amount described in such subparagraph).

``(D) The amount the participant or beneficiary 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 participants and beneficiaries enrolled in the plan, by such separate deductibles or maximums, in addition to any cumulative deductible or maximum).

``(E) 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 participant or beneficiary has accrued towards such limitation with respect to such item or service.

``(F) Any prior authorization, concurrent review, step therapy, fail first, or similar requirements applicable to coverage of such item or service under such plan.

``(G) Any shared savings (such as any credit, payment, or other benefit provided by such plan) available to the participant or beneficiary with respect to such item or service furnished by such provider known at the time such request is made.

``(3) Self-service tool.--For purposes of paragraph (1), a self-service tool established by a group health plan meets the requirements of this paragraph if such tool--

``(A) is based on an Internet website (or successor technology specified by the Secretary);

``(B) provides for real-time responses to requests described in paragraph (1);

``(C) is updated in a manner such that information provided through such tool is timely and accurate at the time such request is made;

``(D) allows such a request to be made with respect to an item or service furnished by--

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

``(ii) all providers that are participating providers with respect to such item or service;

``(E) 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; and

``(F) meets any other requirement determined appropriate by the Secretary to ensure the accessibility and usability of information provided through such tool. The Secretary may require such tool, as a condition of complying with subparagraph (E), to link multiple billing codes to a single descriptive term if the Secretary determines that the billing codes to be so linked correspond to similar items and services.

``(b) Rate and Payment Information.--

``(1) In general.--For plan years beginning on or after January 1, 2026, each group health plan (other than a grandfathered health plan (as defined in section 1251(e) of the Patient Protection and Affordable Care Act)) shall, for each month, not later than the tenth day of such month, make available to the public the rate and payment information described in paragraph (2) in accordance with paragraph (3).

``(2) Rate and payment information described.--For purposes of paragraph (1), the rate and payment information described in this paragraph is, with respect to a group health plan, the following:

``(A) With respect to each item or service (other than a drug) for which benefits are available under such plan, the in-network rate (expressed as a dollar amount) in effect as of the date on which such information is made public with each provider that is a participating provider with respect to such item or service.

``(B) With respect to each drug (identified by national drug code) for which benefits are available under such plan--

``(i) the in-network rate (expressed as a dollar amount) 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; and

``(ii) 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 publication to each provider that was a participating provider with respect to such drug, broken down by each such provider, other than such an amount paid to a provider that, during such period, submitted fewer than 20 claims for such drug to such plan.

``(C) With respect to each item or service for which benefits are available under such plan, the amount billed, and the amount allowed by the plan, for each such item or service furnished during the 90-day period specified in subparagraph (B) by a provider that was not a participating provider with respect to such item or service, broken down by each such provider.

``(3) Manner of publication.--Rate and payment information required to be made available under this subsection shall be so made available in dollar amounts through separate machine- readable files (and any successor technology, such as application program interface technology, determined appropriate by the Secretary) corresponding to the information described in each of subparagraphs (A) through (C) of paragraph (2) that meet such requirements as specified by the Secretary through subregulatory guidance. Such requirements shall ensure that such files are limited to an appropriate size, do not include disclosure of unnecessary duplicative information contained in other files made available under this subsection, are made available in a widely available format through a publicly available website that allows for information contained in such files to be compared across group health plans and group or individual health insurance coverage, and are accessible to individuals at no cost and without the need to establish a user account or provide other credentials.

``(4) User instructions.--Each group health plan shall make available to the public instructions written in plain language explaining how individuals may search for information described in paragraph (2) in files submitted in accordance with paragraph (3). The Secretary shall develop and publish through subregulatory guidance a template that such a plan may use in developing instructions for purposes of the preceding sentence.

``(5) Summary.--For each plan year beginning on or after January 1, 2026, each group health plan shall make public a data file, in a manner that ensures that such file may be easily downloaded and read by standard spreadsheet software and that meets such requirements as established by the Secretary, containing a summary of all rate and payment information made public by such plan with respect to such plan during such plan year. Such file shall include the following:

``(A) The mean, median, and interquartile range of the in- network rate, and the amount allowed for an item or service when not furnished by a participating provider, in effect as of the first day of such plan year for each item or service (identified by payer identifier approved or used by the Centers for Medicare & Medicaid Services) for which benefits are available under the plan, broken down by the type of provider furnishing the item or service and by the geographic area in which such item or service is furnished.

``(B) Trends in payment rates for such items and services over such plan year, including an identification of instances in which such rates have increased, decreased, or remained the same.

``(C) The name of such plan, a description of the type of network of participating providers used by such plan, and a description of whether such plan is self-insured or fully- insured.

``(D) For each item or service which is paid as part of a bundled rate--

``(i) a description of the formulae, pricing methodologies, or other information used to calculate the payment rate for such bundle; and

``(ii) a list of the items and services included in such bundle.

``(E) The percentage of items and services that are paid for on a fee-for-service basis and the percentage of items and services that are paid for as part of a bundled rate, capitated payment rate, or other alternative payment model.

``(6) Attestation.--Each group health plan shall post, along with rate and payment information made public by such plan, an attestation that such information is complete and accurate.

``(c) Accessibility.--A group health plan shall take reasonable steps (as specified by the Secretary) to ensure that information provided in response to a request described in subsection (a), and rate and payment information made public under subsection (b), is provided in plain, easily understandable language and that interpretation, translations, and assistive services are provided to those with limited English proficiency and those with disabilities.

``(d) Definitions.--In this section:

``(1) Participating provider.--The term `participating provider' means, with respect to an item or service and a group health plan, a physician or other health care provider who is acting within the scope of practice of that provider's license or certification under applicable State law and who has a contractual relationship with the plan, respectively, for furnishing such item or service under the plan, and includes facilities, respectively.

``(2) Provider.--The term `provider' includes a health care facility.

``(3) In-network rate.--The term `in-network rate' means, with respect to a group 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 (reflected as a dollar amount) in effect between such plan and such provider for such item or service, regardless of whether such rate is calculated based on a set amount, a fee schedule, or an amount derived from another amount, or a formula, or other method.''.

(B) Clerical amendment.--The item relating to section 9819 of the table of sections for subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended to read as follows: ``Sec. 9819. Transparency in coverage.''.

(2) PHSA.--Section 2799A-4 of the Public Health Service Act (42 U.S.C. 300gg-114) is amended to read as follows: ``SEC. 2799A-4. TRANSPARENCY IN COVERAGE.

``(a) Cost-sharing Transparency.--

``(1) In general.--For plan years beginning on or after January 1, 2026, a group health plan and a health insurance issuer offering group or individual health insurance coverage shall permit an individual enrolled under such plan or coverage to learn the amount of cost-sharing (including deductibles, copayments, and coinsurance) under the individual's plan or coverage that the individual would be responsible for paying with respect to the furnishing of a specific item or service by a provider in a timely manner upon the request of the individual. At a minimum, such information shall include the information specified in paragraph (2) and shall be made available to such individual through a self-service tool that meets the requirements of paragraph (3) or, at the option of such individual, through a paper disclosure or phone or other electronic disclosure (as selected by such individual and provided at no cost to such individual) that meets such requirements as the Secretary may specify.

``(2) Specified information.--For purposes of paragraph (1), the information specified in this paragraph is, with respect to an item or service for which benefits are available under a group health plan or group or individual health insurance coverage furnished by a health care provider to an individual enrolled under such plan or coverage, the following:

``(A) If such provider is a participating provider with respect to such item or service, the in-network rate (as defined in subsection (c)) for such item or service.

``(C) The estimated 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 subparagraph (B), shall be calculated using the maximum allowed amount or other dollar amount described in such subparagraph).

``(D) The amount the individual has already accumulated with respect to any deductible or out of pocket maximum under the plan or coverage (broken down, in the case separate deductibles or maximums apply to separate individuals enrolled in the plan or coverage, by such separate deductibles or maximums, in addition to any cumulative deductible or maximum).

``(E) 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.

``(F) Any prior authorization, concurrent review, step therapy, fail first, or similar requirements applicable to coverage of such item or service under such plan or coverage.

``(G) Any shared savings (such as any credit, payment, or other benefit provided by such plan or issuer) available to the individual with respect to such item or service furnished by such provider known at the time such request is made.

``(3) Self-service tool.--For purposes of paragraph (1), a self-service tool established by a group health plan or health insurance issuer offering group or individual health insurance coverage meets the requirements of this paragraph if such tool--

``(A) is based on an internet website (or successor technology specified by the Secretary);

``(B) provides for real-time responses to requests described in paragraph (1);

``(C) is updated in a manner such that information provided through such tool is timely and accurate at the time such request is made;

``(D) allows such a request to be made with respect to an item or service furnished by--

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

``(ii) all providers that are participating providers with respect to such item or service;

``(b) Rate and Payment Information.--

``(1) In general.--For plan years beginning on or after January 1, 2026, each group health plan and health insurance issuer offering group or individual health insurance coverage (other than a grandfathered health plan (as defined in section 1251(e) of the Patient Protection and Affordable Care Act)) shall, for each month, not later than the tenth day of such month, make available to the public the rate and payment information described in paragraph (2) in accordance with paragraph (3).

``(2) Rate and payment information described.--For purposes of paragraph (1), the rate and payment information described in this paragraph is, with respect to a group health plan or group or individual health insurance coverage, the following:

``(A) With respect to each item or service (other than a drug) for which benefits are available under such plan or coverage, the in-network rate (expressed as a dollar amount) in effect as of the date on which such information is made public with each provider that is a participating provider with respect to such item or service.

``(B) With respect to each drug (identified by national drug code) for which benefits are available under such plan or coverage--

``(C) With respect to each item or service for which benefits are available under such plan or coverage, the amount billed, and the amount allowed by the plan, for each such item or service furnished during the 90-day period specified in subparagraph (B) by a provider that was not a participating provider with respect to such item or service, broken down by each such provider.

``(3) Manner of publication.--Rate and payment information required to be made available under this subsection shall be so made available in dollar amounts through separate machine- readable files (and any successor technology, such as application program interface technology, determined appropriate by the Secretary) corresponding to the information described in each of subparagraphs (A) through (C) of paragraph (2) that meet such requirements as specified by the Secretary through subregulatory guidance. Such requirements shall ensure that such files are limited to an appropriate size, do not include disclosure of unnecessary duplicative information contained in other files made available under this subsection, are made available in a widely-available format through a publicly-available website that allows for information contained in such files to be compared across group health plans and group or individual health insurance coverage, and are accessible to individuals at no cost and without the need to establish a user account or provide other credentials.

``(4) User instructions.--Each group health plan and health insurance issuer offering group or individual health insurance coverage shall make available to the public instructions written in plain language explaining how individuals may search for information described in paragraph (2) in files submitted in accordance with paragraph (3). The Secretary shall develop and publish through subregulatory guidance a template that such a plan may use in developing instructions for purposes of the preceding sentence.

``(5) Summary.--For each plan year beginning on or after January 1, 2026, each group health plan and health insurance issuer offering group or individual health insurance coverage shall make public a data file, in a manner that ensures that such file may be easily downloaded and read by standard spreadsheet software and that meets such requirements as established by the Secretary, containing a summary of all rate and payment information made public by such plan or issuer with respect to such plan or coverage during such plan year. Such file shall include the following:

``(A) The mean, median, and interquartile range of the in- network rate, and the amount allowed for an item or service when not furnished by a participating provider, in effect as of the first day of such plan year for each item or service (identified by payer identifier approved or used by the Centers for Medicare & Medicaid Services) for which benefits are available under the plan or coverage, broken down by the type of provider furnishing the item or service and by the geographic area in which such item or service is furnished.

``(B) Trends in payment rates for such items and services over such plan year, including an identification of instances in which such rates have increased, decreased, or remained the same.

``(C) The name of such plan, a description of the type of network of participating providers used by such plan or coverage, and, in the case of a group health plan, a description of whether such plan is self-insured or fully- insured.

``(D) For each item or service which is paid as part of a bundled rate--

``(i) a description of the formulae, pricing methodologies, or other information used to calculate the payment rate for such bundle; and

``(ii) a list of the items and services included in such bundle.

``(6) Attestation.--Each group health plan and health insurance issuer offering group or individual health insurance coverage shall post, along with rate and payment information made public by such plan or issuer, an attestation that such information is complete and accurate.

``(c) Accessibility.--A group health plan and a health insurance issuer offering group or individual health insurance coverage shall take reasonable steps (as specified by the Secretary) to ensure that information provided in response to a request described in subsection (a), and rate and payment information made public under subsection (b), is provided in plain, easily understandable language and that interpretation, translations, and assistive services are provided to those with limited English proficiency and those with disabilities.

``(d) Definitions.--In this section:

``(1) Participating provider.--The term `participating provider' means, with respect to an item or service and a group health plan or health insurance issuer offering group or individual health insurance coverage, a physician or other health care provider who is acting within the scope of practice of that provider's license or certification under applicable State law and who has a contractual relationship with the plan or issuer, respectively, for furnishing such item or service under the plan or coverage, and includes facilities, respectively.

``(2) Provider.--The term `provider' includes a health care facility.

``(3) In-network rate.--The term `in-network rate' means, with respect to a group health plan or group or individual health insurance coverage and an item or service furnished by a provider that is a participating provider with respect to such plan or coverage and item or service, the contracted rate (reflected as a dollar amount) in effect between such plan or coverage and such provider for such item or service, regardless of whether such rate is calculated based on a set amount, a fee schedule, or an amount derived from another amount, or a formula, or other method.''.

(3) ERISA.--

(A) In general.--Section 719 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185h) is amended to read as follows: ``SEC. 719. TRANSPARENCY IN COVERAGE.

``(a) Cost-Sharing Transparency.--

``(1) In general.--For plan years beginning on or after January 1, 2026, a group health plan and a health insurance issuer offering group health insurance coverage shall permit a participant or beneficiary to learn the amount of cost- sharing (including deductibles, copayments, and coinsurance) under the participant or beneficiary's plan or coverage that the participant or beneficiary would be responsible for paying with respect to the furnishing of a specific item or service by a provider in a timely manner upon the request of the participant or beneficiary. At a minimum, such information shall include the information specified in paragraph (2) and shall be made available to such participant or beneficiary through a self-service tool that meets the requirements of paragraph (3) or, at the option of such participant or beneficiary, through a paper disclosure or phone or other electronic disclosure (as selected by such participant or beneficiary and provided at no cost to such participant or beneficiary) that meets such requirements as the Secretary may specify.

``(2) Specified information.--For purposes of paragraph (1), the information specified in this paragraph is, with respect to an item or service for which benefits are available under a group health plan or group health insurance coverage furnished by a health care provider to a participant or beneficiary of such plan or coverage, the following:

``(A) If such provider is a participating provider with respect to such item or service, the in-network rate (as defined in subsection (c)) for such item or service.

``(C) The estimated amount of cost-sharing (including deductibles, copayments, and coinsurance) that the participant or beneficiary will incur for such item or service (which, in the case such item or service is to be furnished by a provider described in subparagraph (B), shall be calculated using the maximum allowed amount or other dollar amount described in such subparagraph).

``(D) The amount the participant or beneficiary has already accumulated with respect to any deductible or out of pocket maximum under the plan or coverage (broken down, in the case separate deductibles or maximums apply to separate participants and beneficiaries enrolled in the plan or coverage, by such separate deductibles or maximums, in addition to any cumulative deductible or maximum).

``(F) Any prior authorization, concurrent review, step therapy, fail first, or similar requirements applicable to coverage of such item or service under such plan or coverage.

``(G) Any shared savings (such as any credit, payment, or other benefit provided by such plan or issuer) available to the participant or beneficiary with respect to such item or service furnished by such provider known at the time such request is made.

``(3) Self-service tool.--For purposes of paragraph (1), a self-service tool established by a group health plan or health insurance issuer offering group health insurance coverage meets the requirements of this paragraph if such tool--

``(A) is based on an internet website (or successor technology specified by the Secretary);

``(B) provides for real-time responses to requests described in paragraph (1);

``(C) is updated in a manner such that information provided through such tool is timely and accurate at the time such request is made;

``(D) allows such a request to be made with respect to an item or service furnished by--

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

``(ii) all providers that are participating providers with respect to such item or service;

``(b) Rate and Payment Information.--

``(1) In general.--For plan years beginning on or after January 1, 2026, each group health plan and health insurance issuer offering group health insurance coverage (other than a grandfathered health plan (as defined in section 1251(e) of the Patient Protection and Affordable Care Act)) shall, for each month, not later than the tenth day of such month, make available to the public the rate and payment information described in paragraph (2) in accordance with paragraph (3).

``(B) With respect to each drug (identified by national drug code) for which benefits are available under such plan or coverage--

``(4) User instructions.--Each group health plan and health insurance issuer offering group health insurance coverage shall make available to the public instructions written in plain language explaining how individuals may search for information described in paragraph (2) in files submitted in accordance with paragraph (3). The Secretary shall develop and publish through subregulatory guidance a template that such a plan may use in developing instructions for purposes of the preceding sentence.

``(5) Summary.--For each plan year beginning on or after January 1, 2026, each group health plan and health insurance issuer offering group health insurance coverage shall make public a data file, in a manner that ensures that such file may be easily downloaded and read by standard spreadsheet software and that meets such requirements as established by the Secretary, containing a summary of all rate and payment information made public by such plan or issuer with respect to such plan or coverage during such plan year. Such file shall include the following:

``(A) The mean, median, and interquartile range of the in- network rate, and the amount allowed for an item or service when not furnished by a participating provider, in effect as of the first day of such plan year for each item or service (identified by payer identifier approved or used by the Centers for Medicare & Medicaid Services) for which benefits are available under the plan or coverage, broken down by the type of provider furnishing the item or service and by the geographic area in which such item or service is furnished.

``(B) Trends in payment rates for such items and services over such plan year, including an identification of instances in which such rates have increased, decreased, or remained the same.

``(D) For each item or service which is paid as part of a bundled rate--

``(i) a description of the formulae, pricing methodologies, or other information used to calculate the payment rate for such bundle; and

``(ii) a list of the items and services included in such bundle.

``(6) Attestation.--Each group health plan and health insurance issuer offering group health insurance coverage shall post, along with rate and payment information made public by such plan or issuer, an attestation that such information is complete and accurate.

``(c) Accessibility.--A group health plan and a health insurance issuer offering group health insurance coverage shall take reasonable steps (as specified by the Secretary) to ensure that information provided in response to a request described in subsection (a), and rate and payment information made public under subsection (b), is provided in plain, easily understandable language and that interpretation, translations, and assistive services are provided to those with limited English proficiency and those with disabilities.

``(d) Definitions.--In this section:

``(2) Provider.--The term `provider' includes a health care facility.

``(3) In-network rate.--The term `in-network rate' means, with respect to a group health plan or group health insurance coverage and an item or service furnished by a provider that is a participating provider with respect to such plan or coverage and item or service, the contracted rate (reflected as a dollar amount) in effect between such plan or coverage and such provider for such item or service, regardless of whether such rate is calculated based on a set amount, a fee schedule, or an amount derived from another amount, or a formula, or other method.''.

(B) Clerical amendment.--The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 is amended by striking the item relating to section 719 and inserting the following new item: ``Sec. 719. Transparency in coverage.''.

(b) Application Programming Interface Report.--Not later than January 1, 2025, and annually thereafter, the Secretary of Health and Human Services shall, in consultation with the Office of the National Coordinator for Health Information Technology, Department of Labor, the Department of the Treasury, and stakeholders, submit to the House Committees on Education and the Workforce, Energy and Commerce, and Ways and Means, and the Senate Committees on Finance and Health, Education, Labor, and Pensions a report on the use of standards-based application programming interfaces (in this subsection referred to as ``APIs'') to facilitate access to health care price transparency information and the interoperability of other medical information. Such report shall include an evaluation of the capacity of the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury to regulate and implement standards related to APIs and recommendations for improving such capacity. Such report shall include the following:

(1) A description of current use, and proposed use, of APIs under Federal rules to facilitate interoperability, including information related to capacity constraints within the agencies, barriers to adoption, privacy and security, administrative burdens and efficiencies, care coordination, and levels of compliance.

(2) A description of the feasibility of agency participation in the development of APIs to enable application access to price transparency data under the amendments made by subsection (a).

(3) A specification of the timeline for which such data standards can be required to make such data accessible via an API.

(4) An analysis of the benefits and challenges of implementing standards-based APIs for price transparency data, including the ability for consumers to access rate and payment information and the amount of cost-sharing (including deductibles, copayments, and coinsurance) under the consumer's plan through third-party internet-based tools and applications.

(5) An analysis of the impact that APIs which provide real- time access to pricing and cost-sharing information may have in increasing the amount of services shoppable for individuals, such as by standardizing more health care spend via episode bundles.

(6) An analysis of which health care items and services may be useful under API, such as those for which prices change with the greatest frequency.

(7) An analysis of the cost of API standards implementation on issuers, employers, and other private-sector entities.

(8) An analysis of the ability of State regulators to enforce API standards and the costs to the Federal Government and States to regulate and enforce API standards.

(9) An analysis of the interaction with API standards and Federal health information privacy standards.

(1) In general.--Not later than 1 year after the date of the enactment of this Act, The Secretary of Health and Human Services, acting through the Administrator of the Centers for Medicare & Medicaid Services, shall, in consultation with stakeholders, conduct a study and submit to the House Committees on Education and the Workforce, Energy and Commerce, and Ways and Means, and the Senate Committees on Finance and Health, Education, Labor, and Pensions a report on the usefulness and feasibility of the establishment of a provider tool by a group health plan, or a health insurance issuer offering group and individual health insurance coverage, in facilitating the provision of information made available pursuant to the amendments made by subsection (a). Such report shall include the following:

(A) A description of the feasibility of establishing a requirement for the various types of plans and coverage to offer such a provider tool, including any challenges to establishing a provider tool using the same technology platform as the self-service tool described in such amendments.

(B) An evaluation on the usefulness of a provider tool to aid patient-decision making and how such tool would coordinate with other information available to a patient and their provider under other Federal requirements in place or under consideration.

(C) An evaluation of whether the information provided by such tool would be duplicative of the advanced explanation of benefits required under Federal law or any other existing requirement.

(D) A description of the usability and expected utilization of such tool among providers, including among different provider types.

(E) An analysis of the impact of a provider tool in value- based care arrangements.

(F) An analysis on the potential impact of the provider tool on--

(i) patients' out-of-pocket spending;

(ii) plan design, including impacts on cost-sharing requirements;

(iii) care coordination and quality;

(iv) plan premiums;

(v) overall health care spending and utilization; and

(vi) health care access in rural areas.

(G) An analysis of the feasibility of a provider tool to include additional functionality to facilitate and improve the administration of the requirements on providers to submit notifications to such plan or coverage under section 2799B-6 of the Public Health Service Act and the requirements on such plan or coverage to provide an advanced explanation of benefits to individuals under section 2799A-1(f) of such Act.

(H) An analysis of which health care items and services, would be most useful for patients utilizing a provider tool.

(I) An analysis of rulemaking required to ensure such a tool complies with federal health information privacy standards.

(J) An analysis of the burden and cost of the creation of a provider tool by plans and coverage on providers, issuers, employers, and other private-sector entities.

(K) An analysis of the ability of state regulators to enforce provider tool standards and the costs to the Department and states to regulate and enforce provider tool standards.

(2) Definition.--The term ``provider tool'' means a tool designed to facilitate the provision of information made available pursuant to the amendments made by subsection (a) and established by a group health plan or a health insurance issuer offering group and individual health insurance coverage that allows providers to access the information such plan or coverage must provide through the self-service tool described in such amendments to an individual with whom the provider is actively treating at the time of such request, upon the request of the provider, and with the consent of such individual.

(d) Reports.--

(1) Compliance.--Not later than January 1, 2027, the Comptroller General of the United States shall submit to Congress a report containing--

(A) an analysis of 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;

(D) recommendations relating to improving public disclosure, and public awareness, of information required to be made available by group health plans and health insurance issuers pursuant to such amendments.

(2) Prices.--Not later than January 1, 2028, and biennially thereafter, the Secretaries of Health and Human Services, Labor, and the Treasury shall jointly 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 of Health and Human Services);

(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.

(e) Quality Report.--Not later than 1 year after the date of enactment of this subsection, the Secretaries of Health and Human Services, Labor, and the Treasury shall jointly submit to Congress a report on the feasibility of including data relating to the quality of health care items and services with the price transparency information required to be made available under the amendments made by subsection (a). Such report shall include recommendations for legislative and regulatory actions to identify appropriate metrics for assessing and comparing quality of care.

(f) Continued Applicability of Rules for Previous Years.-- Nothing in the amendments made by subsection (a) 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), for any plan year beginning before January 1, 2026. SEC. 106. PHARMACY BENEFITS PRICE TRANSPARENCY.

(a) PHSA.--Title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) is amended--

(1) in part D (42 U.S.C. 300gg-111 et seq.), by adding at the end the following new section: ``SEC. 2799A-11. OVERSIGHT OF PHARMACY BENEFITS MANAGER SERVICES.

``(a) In General.--For plan years beginning on or after the date that is 2 years after the date of enactment of this section, a group health plan or a health insurance issuer offering group health insurance coverage, or an entity or subsidiary providing pharmacy benefits management services on behalf of such a plan or issuer, shall not enter into a contract with a drug manufacturer, distributor, wholesaler, subcontractor, rebate aggregator, or any other third party that 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 making the reports described in subsection (b).

``(b) Reports.--

``(1) In general.--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 every 6 months (or at the request of a group health plan, not less frequently than quarterly, but under the same conditions, terms, and cost of the semiannual report under this subsection), a group health plan or health insurance issuer offering group health insurance coverage, or an entity providing pharmacy benefits management services on behalf of such a plan or issuer, shall submit to the group health plan a report in accordance with this section. Each such report shall be made available to such group health plan in a machine-readable format and shall include the information described in paragraph (2).

``(2) Information described.--For purposes of paragraph (1), the information described in this paragraph is, with respect to drugs covered by a group health plan or health insurance issuer offering group health insurance coverage during each reporting period--

``(A) in the case of such a plan offered by a specified large employer (or such coverage offered in connection with such a plan offered by a specified large employer)--

``(i) a list of drugs for which a claim was filed and, with respect to each such drug on such list--

``(I) the brand name, chemical entity, and National Drug Code;

``(II) the type of dispensing channel used to furnish such drug, including retail, mail order, or specialty pharmacy;

``(III) with respect to each drug dispensed under each type of dispensing channel (including retail, mail order, or specialty pharmacy)--

``(aa) whether such drug is a brand name drug or a generic drug, and--

``(AA) in the case of a brand name drug, the wholesale acquisition cost, listed as cost per days supply and cost per dosage unit, on the date such drug was dispensed; and

``(BB) in the case of a generic drug, the average wholesale price, listed as cost per days supply and cost per dosage unit, on the date such drug was dispensed; and

``(bb) the total number of--

``(AA) prescription claims (including original prescriptions and refills);

``(BB) participants, beneficiaries, and enrollees for whom a claim for such drug was filed;

``(CC) dosage units per fill of such drug; and

``(DD) days supply of such drug per fill;

``(IV) the net price per course of treatment or single fill, such as a 30-day supply or 90-day supply to the plan or coverage after manufacturer rebates, fees, and other remuneration or adjustments;

``(V) the total amount of out-of-pocket spending by participants, beneficiaries, and enrollees on such drug, including spending through copayments, coinsurance, and deductibles;

``(VI) the total net spending by the plan or coverage during the reporting period;

``(VII) the total amount received, or expected to be received, by the plan or coverage from any entity in drug manufacturer rebates, fees, alternative discounts, and all other remuneration received from an entity or any third party (including group purchasing organizations) other than the plan sponsor;

``(VIII) the total amount received, or expected to be received by the plan or issuer, from drug manufacturers in rebates, fees, alternative discounts, or other remuneration--

``(aa) that has been paid, or is to be paid, by drug manufacturers for claims incurred during the reporting period; and

``(bb) that is related to utilization rebates for such drug; and

``(IX) to the extent feasible, information on the total amount of remuneration, including copayment assistance dollars paid, copayment cards applied, or other discounts provided by each drug manufacturer (or entity administering copay assistance on behalf of such drug manufacturer) to the participants, beneficiaries, and enrollees enrolled in such plan or coverage for such drug;

``(ii) for each category or class of drugs for which a claim was filed, a breakdown of the total gross spending on drugs in such category or class before rebates, price concessions, alternative discounts, or other remuneration from drug manufacturers, and the net spending after such rebates, price concessions, alternative discounts, or other remuneration from drug manufacturers, including--

``(I) the number of participants, beneficiaries, and enrollees who filled a prescription for a drug in such category or class, including the National Drug Code for each such drug;

``(II) if applicable, a description of the formulary tiers and utilization mechanisms (such as prior authorization or step therapy) employed for drugs in that category or class; and

``(III) the total out-of-pocket spending under the plan or coverage by participants, beneficiaries, and enrollees, including spending through copayments, coinsurance, and deductibles;

``(iii) in the case of a drug for which gross spending by such plan, coverage, or entity exceeded $10,000 during the reporting period--

``(I) a list of all other drugs in the same therapeutic category or class; and

``(II) the rationale for the formulary placement of such drug in that therapeutic category or class, if applicable; and

``(iv) in the case such plan or coverage (or an entity providing pharmacy benefits management services on behalf of such plan or coverage) has an affiliated pharmacy or pharmacy under common ownership--

``(I) the percentage of total prescriptions dispensed by such pharmacies to individuals enrolled in such plan or coverage;

``(II) a list of all drugs dispensed by such pharmacies to individuals enrolled in such plan or coverage, and, with respect to each drug dispensed--

``(aa) the amount charged, per dosage unit, per 30-day supply, or per 90-day supply (as applicable) to the plan or issuer, and to participants, beneficiaries, and enrollees enrolled in such plan or coverage;

``(bb) the median amount charged to such plan or issuer, and the interquartile range of the costs, per dosage unit, per 30-day supply, and per 90-day supply, including amounts paid by the participants, beneficiaries, and enrollees, when the same drug is dispensed by other pharmacies that are not affiliated with or under common ownership with the entity and that are included in the pharmacy network of such plan or coverage;

``(cc) the lowest cost per dosage unit, per 30-day supply and per 90-day supply, for each such drug, including amounts charged to the plan and participants, beneficiaries, and enrollees, that is available from any pharmacy included in the network of such plan or coverage; and

``(dd) the net acquisition cost per dosage unit, per 30-day supply, and per 90-day supply, if such drug is subject to a maximum price discount;

``(B) in the case of a plan or coverage not described in subparagraph (A)--

``(i) the total net spending by the plan or coverage for all drugs covered by such plan or coverage during such reporting period;

``(ii) the total amount received, or expected to be received, by the plan or coverage from any entity in drug manufacturer rebates, fees, alternative discounts, and all other remuneration received from an entity or any third party (including group purchasing organizations) other than the plan sponsor for all such drugs; and

``(iii) to the extent feasible, information on the total amount of remuneration, including copayment assistance dollars paid, copayment cards applied, or other discounts provided by each drug manufacturer (or entity administering copay assistance on behalf of such drug manufacturer) to the participants, beneficiaries, and enrollees enrolled in such plan or coverage for such drugs;

``(C) amounts paid directly or indirectly in rebates, fees, or any other type of compensation (as defined in section 408(b)(2)(B)(ii)(dd)(AA) of the Employee Retirement Income Security Act) to brokers, consultants, advisors, or any other individual or firm, for the referral of the group health plan's or health insurance issuer's business to an entity providing pharmacy benefits management services, including the identity of the recipient of such amounts;

``(D) an explanation of any benefit design parameters that encourage or require participants, beneficiaries, and enrollees in such plan or coverage to fill prescriptions at mail order, specialty, or retail pharmacies that are affiliated with or under common ownership with the entity providing pharmacy benefit management services under such plan or coverage, including mandatory mail and specialty home delivery programs, retail and mail auto-refill programs, and cost-sharing assistance incentives directly or indirectly funded by such entity; and

``(E) total gross spending on all drugs during the reporting period.

``(3) Privacy requirements.--

``(A) In general.--Health insurance issuers offering group health insurance coverage and entities providing pharmacy benefits management services on behalf of a group health plan shall provide information under paragraph (1) in a manner consistent with the privacy, security, and breach notification regulations promulgated under section 13402(a) of the Health Information Technology for Clinical Health Act and consistent with the HIPAA privacy regulations (as defined in section 1180(b)(3) of the Social Security Act) and shall restrict the use and disclosure of such information according to such privacy, security, and breach notification regulations and such HIPAA privacy regulations.

``(B) Additional requirements.--

``(i) In general.--An entity providing pharmacy benefits management services on behalf of a group health plan or health insurance issuer offering group health insurance coverage that submits a report under paragraph (1) shall ensure that such report contains only summary health information, as defined in section 164.504(a) of title 45, Code of Federal Regulations (or successor regulations).

``(ii) 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 (as defined in section 1180(b)(3) of the Social Security Act).

``(4) Disclosure and redisclosure.--

``(A) Limitation to business associates.--A group health plan receiving a report under paragraph (1) may disclose such information only to the entity from which the report 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 as permitted by the HIPAA Privacy Rule (45 CFR parts 160 and 164, subparts A and E).

``(B) Clarification regarding public disclosure of information.--Nothing in this section shall prevent a group health plan or health insurance issuer offering group health insurance coverage, or an entity providing pharmacy benefits management services on behalf of such a plan or coverage, from placing reasonable restrictions on the public disclosure of the information contained in a report described in paragraph (1), except that such plan, issuer, or entity may not restrict disclosure of such report 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) Limited form of report.--The Secretary shall define through rulemaking a limited form of the report under paragraph (1) required with respect to group health plans where the plan sponsors of such plans are drug manufacturers, drug wholesalers, or other direct participants in the drug supply chain, in order to prevent anti-competitive behavior.

``(5) Report to gao.--A group health plan or health insurance issuer offering group health insurance coverage, or an entity providing pharmacy benefits management services on behalf of such plan or coverage, shall submit to the Comptroller General of the United States each of the first 4 reports submitted to a group health plan under paragraph (1) and other such reports as requested, in accordance with the privacy requirements under paragraph (3), the disclosure and redisclosure standards under paragraph (4), the standards specified pursuant to paragraph (6), and such other information that the Comptroller General determines necessary to carry out the study under section 106(d) of the Lower Costs, More Transparency Act.

``(6) Standard format.--Not later than 1 year after the date of enactment of this section, the Secretary shall specify through rulemaking standards for group health plans, health insurance issuers offering group health insurance coverage, and entities providing pharmacy benefits management services on behalf of such plans or coverage, required to submit reports under paragraph (1) to submit such reports in a standard format.

``(c) Enforcement.--

``(1) In general.--The Secretary shall enforce this section.

``(2) Failure to provide information.--A health insurance issuer or an entity providing pharmacy benefits management services on behalf of such plan or coverage that violates sub-section (a) or fails to provide the information required under subsection (b) shall be subject to a civil monetary penalty in the amount of $10,000 for each day during which such violation continues or such information is not disclosed or reported.

``(3) False information.--A health insurance issuer or an entity providing pharmacy benefits management services on behalf of such a plan or coverage that knowingly provides false information under this section shall be subject to a civil money penalty in an amount not to exceed $100,000 for each item of false information. Such civil money penalty shall be in addition to other penalties as may be prescribed by law.

``(4) Procedure.--The provisions of section 1128A of the Social Security Act, other than subsections (a) and (b) and the first sentence of subsection (c)(1) of such section shall apply to civil monetary penalties under this subsection in the same manner as such provisions apply to a penalty or proceeding under such section.

``(5) Waivers.--The Secretary may waive penalties under paragraph (2), or extend the period of time for compliance with a requirement of this section, for an entity in violation of this section that has made a good-faith effort to comply with the requirements in this section.

``(d) Rule of Construction.--Nothing in this section shall be construed to permit a group health plan, health insurance issuer, or entity providing pharmacy benefits management services on behalf of such plan or coverage, to restrict disclosure to, or otherwise limit the access of, the Department of Health and Human Services to a report described in subsection (b)(1) or information related to compliance with subsection (a) or (b) by entities subject to such subsection.

``(e) Definitions.--In this section:

``(1) Specified large employer.--The term `specified large employer' means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 50 employees on business days during the preceding calendar year and who employs at least 1 employee on the first day of the plan year.

``(2) Wholesale acquisition cost.--The term `wholesale acquisition cost' has the meaning given such term in section 1847A(c)(6)(B) of the Social Security Act.''; and

(2) in section 2723 (42 U.S.C. 300gg-22)--

(A) in subsection (a)--

(i) in paragraph (1), by inserting ``(other than subsections (a) and (b) of section 2799A-11)'' after ``part D''; and

(ii) in paragraph (2), by inserting ``(other than subsections (a) and (b) of section 2799A-11)'' after ``part D''; and

(B) in subsection (b)--

(i) in paragraph (1), by inserting ``(other than subsections (a) and (b) of section 2799A-11)'' after ``part D'';

(ii) in paragraph (2)(A), by inserting ``(other than subsections (a) and (b) of section 2799A-11)'' after ``part D''; and

(iii) in paragraph (2)(C)(ii), by inserting ``(other than subsections (a) and (b) of section 2799A-11)'' after ``part D''.

(b) ERISA.--

(1) In general.--Subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1021 et seq.) is amended--

(A) in subpart B of part 7 (29 U.S.C. 1185 et seq.), by adding at the end the following: ``SEC. 726. OVERSIGHT OF PHARMACY BENEFIT MANAGER SERVICES.