I
119THCONGRESS
1
STSESSION H. R. 267
To amend the Public Health Service Act to provide for hospital and insurer
price transparency.
IN THE HOUSE OF REPRESENTATIVES
JANUARY9, 2025
Mr. D
AVIDSONintroduced the following bill; which was referred to the
Committee on Energy and Commerce
A BILL
To amend the Public Health Service Act to provide for
hospital and insurer price transparency.
Be it enacted by the Senate and House of Representa-1
tives of the United States of America in Congress assembled, 2
SECTION 1. SHORT TITLE. 3
This Act may be cited as the ‘‘Health Care Prices 4
Revealed and Information to Consumers Explained Trans-5
parency Act’’ or the ‘‘Health Care PRICE Transparency 6
Act’’. 7
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SEC. 2. PRICE TRANSPARENCY REQUIREMENTS. 1
(a) H
OSPITALS.—Section 2718(e) of the Public 2
Health Service Act (42 U.S.C. 300gg–18(e)) is amend-3
ed— 4
(1) by striking ‘‘Each hospital’’ and inserting 5
the following: 6
‘‘(1) I
N GENERAL.—Each hospital’’; 7
(2) by inserting ‘‘, in plain language without 8
subscription and free of charge, in a consumer- 9
friendly, machine-readable format,’’ after ‘‘a list’’; 10
and 11
(3) by adding at the end the following: ‘‘Each 12
hospital shall include in its list of standard charges, 13
along with such additional information as the Sec-14
retary may require with respect to such charges for 15
purposes of promoting public awareness of hospital 16
pricing in advance of receiving a hospital item or 17
service, as applicable, the following: 18
‘‘(A) A description of each item or service 19
provided by the hospital. 20
‘‘(B) The gross charge. 21
‘‘(C) Any payer-specific negotiated charge 22
clearly associated with the name of the third 23
party payer and plan. 24
‘‘(D) The de-identified minimum nego-25
tiated charge. 26
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‘‘(E) The de-identified maximum nego-1
tiated charge. 2
‘‘(F) The discounted cash price. 3
‘‘(G) Any code used by the hospital for 4
purposes of accounting or billing, including 5
Current Procedural Terminology (CPT) code, 6
the Healthcare Common Procedure Coding Sys-7
tem (HCPCS) code, the Diagnosis Related 8
Group (DRG), the National Drug Code (NDC), 9
or other common payer identifier. 10
‘‘(2) D
ELIVERY METHODS AND USE .— 11
‘‘(A) I
N GENERAL.—Each hospital shall 12
make public the standard charges described in 13
paragraph (1) for as many of the 70 Centers 14
for Medicaid & Medicare Services-specified 15
shoppable services that are provided by the hos-16
pital, and as many additional hospital-selected 17
shoppable services as may be necessary for a 18
combined total of at least 300 shoppable serv-19
ices, including the rate at which a hospital pro-20
vides and bills for that shoppable service. If a 21
hospital does not provide 300 shoppable services 22
in accordance with the previous sentence, the 23
hospital shall make public the information spec-24
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ified under paragraph (1) for as many 1
shoppable services as it provides. 2
‘‘(B) D
ETERMINATION BY CMS .—A hos-3
pital shall be deemed by the Centers for Medi-4
care & Medicaid Services to meet the require-5
ments of subparagraph (A) if the hospital main-6
tains an internet-based price estimator tool that 7
meets the following requirements: 8
‘‘(i) The tool provides estimates for as 9
many of the 70 specified shoppable services 10
that are provided by the hospital, and as 11
many additional hospital-selected 12
shoppable services as may be necessary for 13
a combined total of at least 300 shoppable 14
services. 15
‘‘(ii) The tool allows health care con-16
sumers to, at the time they use the tool, 17
obtain an estimate of the amount they will 18
be obligated to pay the hospital for the 19
shoppable service. 20
‘‘(iii) The tool is prominently dis-21
played on the hospital’s website and easily 22
accessible to the public, without subscrip-23
tion, fee, or having to submit personal 24
identifying information (PII), and search-25
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able by service description, billing code, 1
and payer. 2
‘‘(3) D
EFINITIONS.—Notwithstanding any other 3
provision of law, for the purpose of paragraphs (1) 4
and (2): 5
‘‘(A) D
E-IDENTIFIED MAXIMUM NEGO -6
TIATED CHARGE.—The term ‘de-identified max-7
imum negotiated charge’ means the highest 8
charge that a hospital has negotiated with all 9
third party payers for an item or service. 10
‘‘(B) D
E-IDENTIFIED MINIMUM NEGO -11
TIATED CHARGE.—The term ‘de-identified min-12
imum negotiated charge’ means the lowest 13
charge that a hospital has negotiated with all 14
third party payers for an item or service. 15
‘‘(C) D
ISCOUNTED CASH PRICE .—The 16
term ‘discounted cash price’ means the charge 17
that applies to an individual who pays cash, or 18
cash equivalent, for a hospital item or service. 19
Hospitals that do not offer self-pay discounts 20
may display the hospital’s undiscounted gross 21
charges as found in the hospital chargemaster. 22
‘‘(D) G
ROSS CHARGE.—The term ‘gross 23
charge’ means the charge for an individual item 24
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or service that is reflected on a hospital’s 1
chargemaster, absent any discounts. 2
‘‘(E) P
AYER-SPECIFIC NEGOTIATED 3
CHARGE.—The term ‘payer-specific negotiated 4
charge’ means the charge that a hospital has 5
negotiated with a third party payer for an item 6
or service. 7
‘‘(F) S
HOPPABLE SERVICE .—The term 8
‘shoppable service’ means a service that can be 9
scheduled by a health care consumer in ad-10
vance. 11
‘‘(G) S
TANDARD CHARGES .—The term 12
‘standard charges’ means the regular rate es-13
tablished by the hospital for an item or service, 14
including both individual items and services and 15
service packages, provided to a specific group of 16
paying patients, including the gross charge, the 17
payer-specific negotiated charge, the discounted 18
cash price, the de-identified minimum nego-19
tiated charge, the de-identified maximum nego-20
tiated charge, and other rates determined by 21
the Secretary. 22
‘‘(H) T
HIRD PARTY PAYER .—The term 23
‘third party payer’ means an entity that is, by 24
statute, contract, or agreement, legally respon-25
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sible for payment of a claim for a health care 1
item or service. 2
‘‘(4) E
NFORCEMENT.—In addition to any other 3
enforcement actions or penalties that may apply 4
under subsection (b)(3) or another provision of law, 5
a hospital that fails to provide the information re-6
quired by this subsection and has not completed a 7
corrective action plan to comply with the require-8
ments of such subsection shall be subject to a civil 9
monetary penalty of an amount not to exceed $300 10
per day that the violation is ongoing as determined 11
by the Secretary. Such penalty shall be imposed and 12
collected in the same manner as civil money pen-13
alties under subsection (a) of section 1128A of the 14
Social Security Act are imposed and collected.’’. 15
(b) T
RANSPARENCY IN COVERAGE.—Section 16
1311(e)(3) of the Patient Protection and Affordable Care 17
Act (42 U.S.C. 18031(e)(3)) is amended— 18
(1) in subparagraph (A)— 19
(A) by redesignating clause (ix) as clause 20
(xii); and 21
(B) by inserting after clause (viii), the fol-22
lowing: 23
‘‘(ix) In-network provider rates for 24
covered items and services. 25
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‘‘(x) Out-of-network allowed amounts 1
and billed charges for covered items and 2
services. 3
‘‘(xi) Negotiated rates and historical 4
net prices for covered prescription drugs.’’; 5
(2) in subparagraph (B)— 6
(A) in the heading, by striking ‘‘
USE’’ and 7
inserting ‘‘
DELIVERY METHODS AND USE ’’; 8
(B) by inserting ‘‘and subparagraph (C)’’ 9
after ‘‘subparagraph (A)’’; 10
(C) by inserting ‘‘, as applicable,’’ after 11
‘‘English proficiency’’; and 12
(D) by inserting after the second sentence, 13
the following: ‘‘The Secretary shall establish 14
standards for the methods and formats for dis-15
closing information to individuals. At a min-16
imum, these standards shall include the fol-17
lowing: 18
‘‘(i) An internet-based self-service tool 19
to provide information to an individual in 20
plain language, without subscription and 21
free of charge, in a machine readable for-22
mat, through a self-service tool on an 23
internet website that provides real-time re-24
sponses based on cost-sharing information 25
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that is accurate at the time of the request 1
that allows, at a minimum, users to— 2
‘‘(I) search for cost-sharing infor-3
mation for a covered item or service 4
provided by a specific in-network pro-5
vider or by all in-network providers; 6
‘‘(II) search for an out-of-net-7
work allowed amount, percentage of 8
billed charges, or other rate that pro-9
vides a reasonably accurate estimate 10
of the amount an insurer will pay for 11
a covered item or service provided by 12
out-of-network providers; and 13
‘‘(III) refine and reorder search 14
results based on geographic proximity 15
of in-network providers, and the 16
amount of the individual’s cost-shar-17
ing liability for the covered item or 18
service, to the extent the search for 19
cost-sharing information for covered 20
items or services returns multiple re-21
sults. 22
‘‘(ii) In paper form at the request of 23
the individual that includes no fewer than 24
20 providers per request with respect to 25
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which cost-sharing information for covered 1
items and services is provided, and dis-2
closes the applicable provider per-request 3
limit to the individual, mailed to the indi-4
vidual not later than 2 business days after 5
receiving an individual’s request.’’; 6
(3) in subparagraph (C)— 7
(A) in the first sentence— 8
(i) by striking ‘‘The Exchange’’ and 9
inserting the following: 10
‘‘(i) I
N GENERAL.—The Exchange’’; 11
(ii) by inserting ‘‘or out-of-network 12
provider’’ after ‘‘item or service by a par-13
ticipating provider’’; and 14
(iii) by inserting before the period the 15
following: ‘‘the following information: 16
‘‘(i) An estimate of an individual’s 17
cost-sharing liability for a requested cov-18
ered item or service furnished by a pro-19
vider, which shall reflect any cost-sharing 20
reductions the individual would receive. 21
‘‘(ii) A description of the accumulated 22
amounts. 23
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‘‘(iii) The in-network rate, including 1
negotiated rates and underlying fee sched-2
ule rates. 3
‘‘(iv) The out-of-network allowed 4
amount or any other rate that provides a 5
more accurate estimate of an amount an 6
issuer will pay, including the percent reim-7
bursed by insurers to out-of-network pro-8
viders, for the requested covered item or 9
service furnished by an out-of-network pro-10
vider. 11
‘‘(v) A list of the items and services 12
included in bundled payment arrangements 13
for which cost-sharing information is being 14
disclosed. 15
‘‘(vi) A notification that coverage of a 16
specific item or service is subject to a pre-17
requisite, if applicable. 18
‘‘(vii) A notice that includes the fol-19
lowing information: 20
‘‘(I) A statement that out-of-net-21
work providers may bill individuals for 22
the difference, including the balance 23
billing, between a provider’s billed 24
charges and the sum of the amount 25
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collected from the insurer in the form 1
of a copayment or coinsurance 2
amount and the cost-sharing informa-3
tion. 4
‘‘(II) A statement that the actual 5
charges for an individual’s covered 6
item or service may be different from 7
an estimate of cost-sharing liability 8
depending on the actual items or serv-9
ices the individual receives at the 10
point of care. 11
‘‘(III) A statement that the esti-12
mate of cost-sharing liability for a 13
covered item or service is not a guar-14
antee that benefits will be provided 15
for that item or service. 16
‘‘(IV) A statement disclosing 17
whether the plan counts copayment 18
assistance and other third-party pay-19
ments in the calculation of the indi-20
vidual’s deductible and out-of-pocket 21
maximum. 22
‘‘(V) For items and services that 23
are recommended preventive services 24
under section 2713 of the Public 25
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Health Service Act, a statement that 1
an in-network item or service may not 2
be subject to cost-sharing if it is billed 3
as a preventive service in the insurer 4
cannot determine whether the request 5
is for a preventive or non-preventive 6
item or service. 7
‘‘(VI) Any additional informa-8
tion, including other disclaimers, that 9
the insurer determines is appropriate, 10
provided the additional information 11
does not conflict with the information 12
required to be provided by this sub-13
section.’’; 14
(B) by striking the second sentence; and 15
(C) by adding at the end the following: 16
‘‘(ii) D
EFINITIONS.—Notwithstanding 17
any other provision of law, for the purpose 18
of this subparagraph and subparagraphs 19
(A) and (B): 20
‘‘(I) A
CCUMULATED AMOUNTS .— 21
The term ‘accumulated amounts’ 22
means the amount of financial respon-23
sibility an individual has incurred at 24
the time a request for cost-sharing in-25
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formation is made, with respect to a 1
deductible or out-of-pocket limit, in-2
cluding any expense that counts to-3
ward a deductible or out-of-pocket 4
limit, but exclude any expense that 5
does not count toward a deductible or 6
out-of-pocket limit. To the extent an 7
insurer imposes a cumulative treat-8
ment limitation on a particular cov-9
ered item or service independent of in-10
dividual medical necessity determina-11
tions, the amount that has accrued to-12
ward the limit on the item or service. 13
‘‘(II) H
ISTORICAL NET PRICE.— 14
The term ‘historical net price’ means 15
the retrospective average amount an 16
insurer paid for a prescription drug, 17
inclusive of any reasonably allocated 18
rebates, discounts, chargebacks, fees, 19
and any additional price concessions 20
received by the insurer with respect to 21
the prescription drug. The allocation 22
shall be determined by dollar value for 23
non-product specific and product-spe-24
cific rebates, discounts, chargebacks, 25
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fees, and other price concessions to 1
the extent that the total amount of 2
any such price concession is known to 3
the insurer at the time of publication 4
of the historical net price. 5
‘‘(III) N
EGOTIATED RATE.—The 6
term ‘negotiated rate’ means the 7
amount a plan or issuer has contrac-8
tually agreed to pay for a covered 9
item or service, whether directly or in-10
directly through a third party admin-11
istrator or pharmacy benefit manager, 12
to an in-network provider, including 13
an in-network pharmacy or other pre-14
scription drug dispenser, for covered 15
items or services. 16
‘‘(IV) O
UT-OF-NETWORK AL -17
LOWED AMOUNT .—The term ‘out-of- 18
network allowed amount’ means the 19
maximum amount an insurer will pay 20
for a covered item or service furnished 21
by an out-of-network provider. 22
‘‘(V) O
UT-OF-NETWORK LIMIT.— 23
The term ‘out-of-network limit’ means 24
the maximum amount that an indi-25
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vidual is required to pay during a cov-1
erage period for his or her share of 2
the costs of covered items and services 3
under his or her plan or coverage, in-4
cluding for self-only and other than 5
self-only coverage, as applicable. 6
‘‘(VI) U
NDERLYING FEE SCHED -7
ULE RATES.—The term ‘underlying 8
fee schedule rates’ means the rate for 9
an item or service that a plan or 10
issuer uses to determine a partici-11
pant’s, beneficiary’s, or enrollee’s 12
cost-sharing liability from a particular 13
provider or providers, when the rate is 14
different from the negotiated rate.’’; 15
(4) in subparagraph (D), by striking ‘‘subpara-16
graph (A)’’ and inserting ‘‘subparagraphs (A), (B), 17
and (C)’’; and 18
(5) by adding at the end the following: 19
‘‘(F) A
PPLICATION OF PARAGRAPH .—In 20
addition to qualified health plans (and plans 21
seeking certification as qualified health plans), 22
this paragraph (as amended by the Health Care 23
Prices Revealed and Information to Consumers 24
Explained Transparency Act) shall apply to 25
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group health plans (including self-insured and 1
fully insured plans) and health insurance cov-2
erage (as such terms are defined in section 3
2791 of the Public Health Service Act).’’. 4
Æ
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