Health Care PRICE Transparency Act

I 118TH CONGRESS 1ST SESSION H. R. 410 To amend the Public Health Service Act to provide for hospital and insurer price transparency. IN THE HOUSE OF REPRESENTATIVES JANUARY 20, 2023 Mr. DAVIDSON introduced 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 VerDate Sep 11 2014 03:16 Jan 31, 2023 Jkt 039200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H410.IH H410 kjohnson on DSK79L0C42PROD with BILLS 2 •HR 410 IH 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 ‘‘(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 VerDate Sep 11 2014 03:16 Jan 31, 2023 Jkt 039200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H410.IH H410 kjohnson on DSK79L0C42PROD with BILLS 3 •HR 410 IH ‘‘(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) DELIVERY METHODS AND USE.— 11 ‘‘(A) IN 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 VerDate Sep 11 2014 03:16 Jan 31, 2023 Jkt 039200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H410.IH H410 kjohnson on DSK79L0C42PROD with BILLS 4 •HR 410 IH 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 03:16 Jan 31, 2023 Jkt 039200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H410.IH H410 kjohnson on DSK79L0C42PROD with BILLS 5 •HR 410 IH 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 03:16 Jan 31, 2023 Jkt 039200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H410.IH H410 kjohnson on DSK79L0C42PROD with BILLS 6 •HR 410 IH 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 03:16 Jan 31, 2023 Jkt 039200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H410.IH H410 kjohnson on DSK79L0C42PROD with BILLS 7 •HR 410 IH 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 03:16 Jan 31, 2023 Jkt 039200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H410.IH H410 kjohnson on DSK79L0C42PROD with BILLS 8 •HR 410 IH ‘‘(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 03:16 Jan 31, 2023 Jkt 039200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H410.IH H410 kjohnson on DSK79L0C42PROD with BILLS 9 •HR 410 IH 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 03:16 Jan 31, 2023 Jkt 039200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H410.IH H410 kjohnson on DSK79L0C42PROD with BILLS 10 •HR 410 IH 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 03:16 Jan 31, 2023 Jkt 039200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H410.IH H410 kjohnson on DSK79L0C42PROD with BILLS 11 •HR 410 IH ‘‘(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 03:16 Jan 31, 2023 Jkt 039200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H410.IH H410 kjohnson on DSK79L0C42PROD with BILLS 12 •HR 410 IH 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 03:16 Jan 31, 2023 Jkt 039200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\H410.IH H410 kjohnson on DSK79L0C42PROD with BILLS 13 •HR 410 IH 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 this subparagraph and subparagraphs 19 (A) and (B): 20 ‘‘(I) ACCUMULATED 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 f [Text truncated for display. 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