Federal

Health Care PRICE Transparency Act

Source: Congress.gov · 3,192 words in original text

What This Bill Does

This bill requires hospitals and health insurers to share price information with patients before they receive care. Hospitals must post pricing details for hundreds of medical services online. Insurers must give patients tools to see what they will owe for specific medical items and services. ##

Who It Affects

- Hospitals - Health insurers - Health insurance plans - Patients and people seeking medical care - The U.S. Department of Health and Human Services ##

Key Provisions

- Hospitals must post pricing information in plain language, free of charge, in a machine-readable format (a format computers can easily read and search) without requiring people to subscribe or give personal information (Sec. 2(a)) - Hospitals must include pricing for at least 300 shoppable services (services people can schedule in advance), including descriptions, gross charges (the full price before discounts), negotiated rates with specific insurance companies, minimum and maximum negotiated prices, and cash prices (Sec. 2(a)) - Hospitals can meet these requirements either by posting a list of charges or by maintaining an online price estimator tool on their website that is easy to find and use (Sec. 2(a)) - Insurers must provide an online tool where patients can search cost-sharing information (the amount the patient owes) for in-network and out-of-network providers in plain language, without subscription or fees (Sec. 2(b)) - Insurers must mail paper information including at least 20 providers per request within 2 business days if a patient asks for it (Sec. 2(b)) - Insurers must show patients estimates of their cost-sharing liability, accumulated amounts toward their deductible or out-of-pocket maximum, negotiated rates with doctors, and warnings about balance billing (when a doctor bills you for the difference between what insurance pays and what they charge) (Sec. 2(b)) - Hospitals that fail to provide required pricing information can face civil monetary penalties of up to $300 per day the violation continues (Sec. 2(a)) ##

What Changes

Current law requires hospitals to post some pricing information, but this bill adds more specific requirements. Hospitals now must include payer-specific negotiated charges (the prices they negotiated with each insurance company), de-identified minimum and maximum negotiated charges (the lowest and highest prices hospitals negotiated with any insurance company, without naming the company), and discounted cash prices. The bill expands the requirement from fewer services to at least 300 shoppable services. Current law requires some insurers to share pricing information, but this bill adds new requirements. Insurers must now disclose in-network provider rates, out-of-network allowed amounts and billed charges, and negotiated rates and historical net prices for prescription drugs. They must provide this information through multiple methods, including online self-service tools and paper requests. The bill extends these requirements to all group health plans and health insurance coverage, not just certain qualified health plans. ##

Important Definitions

- **De-identified maximum negotiated charge:** The highest price a hospital has negotiated with any insurance company for an item or service (Sec. 2(a)) - **De-identified minimum negotiated charge:** The lowest price a hospital has negotiated with any insurance company for an item or service (Sec. 2(a)) - **Discounted cash price:** The price for people who pay cash instead of using insurance. If hospitals do not offer cash discounts, they can show their regular full price (Sec. 2(a)) - **Gross charge:** The full price for a hospital item or service before any discounts (Sec. 2(a)) - **Payer-specific negotiated charge:** The price a hospital has agreed to accept from a specific insurance company (Sec. 2(a)) - **Shoppable service:** A medical service that a patient can schedule in advance (Sec. 2(a)) - **Standard charges:** The regular prices hospitals set for items and services (Sec. 2(a)) - **Third party payer:** An insurance company or other organization legally responsible for paying medical bills (Sec. 2(a)) - **Accumulated amounts:** The money a patient has already spent toward their deductible (the amount they must pay before insurance kicks in) or out-of-pocket maximum (the most they have to pay per year) (Sec. 2(b)) - **Historical net price:** The average amount an insurer actually paid for a prescription drug after accounting for rebates, discounts, and other price reductions (Sec. 2(b)) - **Negotiated rate:** The price a health plan has agreed to pay a doctor, hospital, or pharmacy for a service or drug (Sec. 2(b)) - **Out-of-network allowed amount:** The maximum amount an insurer will pay for care from a doctor or hospital not in their network (Sec. 2(b)) - **Out-of-network limit:** The most money a patient must pay per year for out-of-network care (Sec. 2(b)) - **Underlying fee schedule rates:** The price a health plan uses to calculate what a patient owes when it differs from the negotiated rate (Sec. 2(b)) ##

Effective Date

Not specified in bill text

II 118TH CONGRESS 1ST SESSION S. 1130 To amend the Public Health Service Act to provide for hospital and insurer price transparency. IN THE SENATE OF THE UNITED STATES MARCH 30, 2023 Mr. BRAUN (for himself and Mr. GRASSLEY) introduced the following bill; which was read twice and referred to the Committee on Health, Edu- cation, Labor, and Pensions A BILL To amend the Public Health Service Act to provide for hospital and insurer price transparency. Be it enacted by the Senate and House of 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 VerDate Sep 11 2014 22:52 Apr 12, 2023 Jkt 039200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\S1130.IS S1130 kjohnson on DSK79L0C42PROD with BILLS 2 •S 1130 IS SEC. 2. PRICE TRANSPARENCY REQUIREMENTS. 1 (a) HOSPITALS.—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) IN 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 ‘‘(i) A description of each item or 19 service provided by the hospital. 20 ‘‘(ii) The gross charge. 21 ‘‘(iii) Any payer-specific negotiated 22 charge clearly associated with the name of 23 the third party payer and plan. 24 ‘‘(iv) The de-identified minimum ne- 25 gotiated charge. 26 VerDate Sep 11 2014 22:52 Apr 12, 2023 Jkt 039200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S1130.IS S1130 kjohnson on DSK79L0C42PROD with BILLS 3 •S 1130 IS ‘‘(v) The de-identified maximum nego- 1 tiated charge. 2 ‘‘(vi) The discounted cash price. 3 ‘‘(vii) Any code used by the hospital 4 for purposes of accounting or billing, in- 5 cluding Current Procedural Terminology 6 (CPT) code, the Healthcare Common Pro- 7 cedure Coding System (HCPCS) code, the 8 Diagnosis Related Group (DRG), the Na- 9 tional Drug Code (NDC), or other common 10 payer identifier. 11 ‘‘(2) DELIVERY METHODS AND USE.— 12 ‘‘(A) IN GENERAL.—Each hospital shall 13 make public the standard charges described in 14 paragraph (1) for as many of the 70 Centers 15 for Medicaid & Medicare Services-specified 16 shoppable services that are provided by the hos- 17 pital, and as many additional hospital-selected 18 shoppable services as may be necessary for a 19 combined total of at least 300 shoppable serv- 20 ices, including the rate at which a hospital pro- 21 vides and bills for that shoppable service. If a 22 hospital does not provide 300 shoppable services 23 in accordance with the previous sentence, the 24 hospital shall make public the information spec- 25 VerDate Sep 11 2014 22:52 Apr 12, 2023 Jkt 039200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S1130.IS S1130 kjohnson on DSK79L0C42PROD with BILLS 4 •S 1130 IS ified under paragraph (1) for as many 1 shoppable services as it provides. 2 ‘‘(B) DETERMINATION 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 VerDate Sep 11 2014 22:52 Apr 12, 2023 Jkt 039200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S1130.IS S1130 kjohnson on DSK79L0C42PROD with BILLS 5 •S 1130 IS able by service description, billing code, 1 and payer. 2 ‘‘(3) DEFINITIONS.—Notwithstanding any other 3 provision of law, for the purpose of paragraphs (1) 4 and (2): 5 ‘‘(A) DE-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) DE-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) DISCOUNTED 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) GROSS CHARGE.—The term ‘gross 23 charge’ means the charge for an individual item 24 VerDate Sep 11 2014 22:52 Apr 12, 2023 Jkt 039200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S1130.IS S1130 kjohnson on DSK79L0C42PROD with BILLS 6 •S 1130 IS or service that is reflected on a hospital’s 1 chargemaster, absent any discounts. 2 ‘‘(E) PAYER-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) SHOPPABLE 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) STANDARD 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) THIRD PARTY PAYER.—The term 23 ‘third party payer’ means an entity that is, by 24 statute, contract, or agreement, legally respon- 25 VerDate Sep 11 2014 22:52 Apr 12, 2023 Jkt 039200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S1130.IS S1130 kjohnson on DSK79L0C42PROD with BILLS 7 •S 1130 IS sible for payment of a claim for a health care 1 item or service. 2 ‘‘(4) ENFORCEMENT.—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) TRANSPARENCY 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 VerDate Sep 11 2014 22:52 Apr 12, 2023 Jkt 039200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S1130.IS S1130 kjohnson on DSK79L0C42PROD with BILLS 8 •S 1130 IS ‘‘(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 VerDate Sep 11 2014 22:52 Apr 12, 2023 Jkt 039200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S1130.IS S1130 kjohnson on DSK79L0C42PROD with BILLS 9 •S 1130 IS 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 VerDate Sep 11 2014 22:52 Apr 12, 2023 Jkt 039200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S1130.IS S1130 kjohnson on DSK79L0C42PROD with BILLS 10 •S 1130 IS 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) IN 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 VerDate Sep 11 2014 22:52 Apr 12, 2023 Jkt 039200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S1130.IS S1130 kjohnson on DSK79L0C42PROD with BILLS 11 •S 1130 IS ‘‘(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 VerDate Sep 11 2014 22:52 Apr 12, 2023 Jkt 039200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S1130.IS S1130 kjohnson on DSK79L0C42PROD with BILLS 12 •S 1130 IS 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 VerDate Sep 11 2014 22:52 Apr 12, 2023 Jkt 039200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\S1130.IS S1130 kjohnson on DSK79L0C42PROD with BILLS 13 •S 1130 IS 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) DEFINITIONS.—Notwithstanding 17 any other provision of law, for the purpose 18 of subparagraphs (A), (B), and (C): 19 ‘‘(I) ACCUMULATED AMOUNTS.— 20 The term ‘accumulated amounts’ 21 means the amount of fin [Text truncated for display. Full text available on Congress.gov.]

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