#aahth ,,congress #ast ,session ,h4 ,r4 #ecgh ,,an ,,act ,to promote price transparency in the health care sector1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,lower ,costs1 ,more ,transparency ,act4 #b4 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title4 ,sec4 #b4 ,table of contents4 ,title ,i--,improving ,health ,care ,transparency ,sec4 #aja4 ,hospital price transparency4 ,sec4 #ajb4 ,clinical diagnostic laboratory test price transparency4 ,sec4 #ajc4 ,imaging price transparency4 ,sec4 #ajd4 ,ambulatory surgical center price transparency4 ,sec4 #aje4 ,health coverage price transparency4 ,sec4 #ajf4 ,pharmacy benefits price transparency4 ,sec4 #ajg4 ,reports on health care transparency tools and data4 ,sec4 #ajh4 ,report on integration in ,medicare4 ,sec4 #aji4 ,advisory ,committee4 ,sec4 #aaj4 ,report on impact of ,medicare regulations on provider and payer consolidation4 ,sec4 #aaa4 ,implementation funding4 ,title ,,ii--,reducing ,health ,care ,costs for ,patients ,sec4 #bja4 ,increasing transparency in generic drug applications4 ,sec4 #bjb4 ,improving transparency and preventing the use of abusive spread pricing and related practices in ,medicaid4 ,sec4 #bjc4 ,parity in ,medicare payments for hospital outpatient department services furnished off-campus4 ,sec4 #bjd4 ,requiring a separate identification number and an attestation for each off-campus outpatient department of a provider4 ,title ,,iii--,supporting ,patients1 ,health ,care ,workers1 ,community ,health ,centers1 and ,hospitals ,sec4 #cja4 ,extension for community health centers1 the national health service corps1 and teaching health centers that operate ,,gme programs4 ,sec4 #cjb4 ,extension of special diabetes programs4 ,sec4 #cjc4 ,delaying certain disproportionate share payment cuts4 ,sec4 #cjd4 ,medicaid improvement fund4 ,title ,,iv--,increasing access to quality health data and lowering hidden fees ,sec4 #dja4 ,increasing ,plan ,fiduciaries' ,access to ,health ,data4 ,sec4 #djb4 ,hidden ,fees ,disclosure ,requirements4 ,sec4 #djc4 ,prescription drug price information requirement4 ,sec4 #djd4 ,implementation funding4 ,i ,improving ,health ,care ,transparency #aja4 ,hospital price transparency 7a7 ,medicare ,part ,e of title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex et seq47 is amended by adding at the end the following new section3 #ahii;,c4 ,hospital price transparency 7a7 ,transparency requirement 7#a7 ,in general ,beginning ,january #a1 #bjbf1 each specified hospital that receives payment under this title for furnishing items and services shall comply with the price transparency requirement described in paragraph 7#b74 7#b7 ,requirement described 7,a7 ,in general ,for purposes of paragraph 7#a71 the price transparency requirement described in this paragraph is1 with respect to a specified hospital1 that such hospital1 in accordance with a method and format established by the ,secretary under subparagraph 7,c71 compile and make public 7without subscription and free of charge7 for each year-- 7i7 all of the hospital's standard charges 7including the information described in subparagraph 7,b77 for each item and service furnished by such hospital2 7ii7 information in a consumer-friendly format 7as specified by the ,secretary7-- 7,i7 on the hospital's prices 7including the information described in subparagraph 7,b77 for as many of the ,centers for ,medicare ,medicaid ,services-specified shoppable services that are furnished by the hospital1 and as many additional hospital-selected shoppable services 7or all such additional services1 if such hospital furnishes fewer than #cjj shoppable services7 as may be necessary for a combined total of at least #cjj shoppable services2 and 7,,ii7 that includes1 with respect to each ,centers for ,medicare ,medicaid ,services-specified shoppable service that is not furnished by the hospital1 an indication that such service is not so furnished2 and 7iii7 an attestation that all information made public pursuant to this subparagraph is complete and accurate4 7,b7 ,information described ,for purposes of subparagraph 7,a71 the information described in this subparagraph is1 with respect to standard charges and prices1 as applicable1 made public by a specified hospital1 the following3 7i7 ,a plain language description of each item or service1 accompanied by1 as applicable1 the ,healthcare ,common ,procedure ,coding ,system code1 the diagnosis-related group1 the national drug code1 or other identifier used or approved by the ,centers for ,medicare ,medicaid ,services4 7ii7 ,the gross charge1 as applicable1 expressed as a dollar amount1 for each such item or service1 when provided in1 as applicable1 the inpatient setting and outpatient department setting4 7iii7 ,the discounted cash price1 as applicable1 expressed as a dollar amount1 for each such item or service when provided in1 as applicable1 the inpatient setting and outpatient department setting 7or1 in the case no discounted cash price is available for an item or service1 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 years1 expressed as a dollar amount1 as well as1 with respect to prices made public pursuant to subparagraph 7,a77ii71 a link to a consumer-friendly document that clearly explains the hospital's charity care policy that includes1 if applicable1 any sliding scale payment structure employed for determining charges for a self-pay individual74 7iv7 ,the payer-specific negotiated charges1 as applicable1 clearly associated with the name of the third party payer and plan and expressed as a dollar amount1 that apply to each such item or service when provided in1 as applicable1 the inpatient setting and outpatient department setting4 7v7 ,the de-identified maximum and minimum negotiated charges1 as applicable1 for each such item or service4 7vi7 ,any other additional information the ,secretary may require for the purpose of improving the accuracy of1 or enabling consumers to easily understand and compare1 standard charges and prices for an item or service1 except information that is duplicative of any other reporting requirement under this subsection4 ,in the case of standard charges and prices for an item or service included as part of a bundled1 per diem1 episodic1 or other similar arrangement1 the information described in this subparagraph shall be made available as determined appropriate by the ,secretary4 7,c7 ,uniform method and format ,not later than ,january #a1 #bjbf1 the ,secretary shall establish a standard1 uniform method and format for specified hospitals to use in compiling and making public standard charges pursuant to subparagraph 7,a77i7 and a standard1 uniform method and format for such hospitals to use in compiling and making public prices pursuant to subparagraph 7,a77ii74 ,such methods and formats-- 7i7 shall1 in the case of such method and format for making public standard charges pursuant to subparagraph 7,a77i71 ensure that such charges are made available in a machine-readable format 7or a successor technology specified by the ,secretary72 7ii7 may be similar to any template made available by the ,centers for ,medicare ,medicaid ,services as of the date of the enactment of this subparagraph2 7iii7 shall meet such standards as determined appropriate by the ,secretary in order to ensure the accessibility and usability of such charges and prices2 and 7iv7 shall be updated as determined appropriate by the ,secretary1 in consultation with stakeholders4 7#c7 ,monitoring compliance ,the ,secretary shall1 through notice and comment rulemaking and in consultation with the ,inspector ,general of the ,department of ,health and ,human ,services1 establish a process to monitor compliance with this subsection4 ,such process shall ensure that each specified hospital's compliance with this subsection is reviewed not less frequently than once every #c years4 7#d7 ,enforcement 7,a7 ,in general ,in the case of a specified hospital that fails to comply with the requirements of this subsection-- 7i7 not later than #cj days after the date on which the ,secretary determines such failure exists1 the ,secretary shall submit to such hospital a notification of such determination 7which may include1 as determined appropriate by the ,secretary1 a request for a corrective action plan to comply with such requirements72 and 7ii7 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 7i7-- 7,i7 the ,secretary shall1 not later than #de days after such notification is sent1 determine whether such hospital is in compliance with such requirements2 and 7,,ii7 if the ,secretary determines under subclause 7,i7 that such hospital is not in compliance with such requirements1 the ,secretary shall either-- 7aa7 submit to such hospital a request for a corrective action plan to comply with such requirements2 or 7bb7 if the ,secretary determines that such hospital has not taken meaningful actions to come into compliance since such notification was sent1 impose a civil monetary penalty in accordance with subparagraph 7,b74 7,b7 ,civil monetary penalty 7i7 ,in general ,subject to clause 7vii71 in addition to any other enforcement actions or penalties that may apply under another provision of law1 a specified hospital that has received a request for a corrective action plan under clause 7i7 or 7ii7 of subparagraph 7,a7 and fails to comply with the requirements of this subsection by the date that is #de days after such request is made1 and a specified hospital with respect to which the ,secretary has made a determination described in clause 7ii77,,ii77bb7 of such subparagraph1 shall be subject to a civil monetary penalty of an amount specified by the ,secretary for each day 7beginning with the day on which the ,secretary first determined that such hospital was not complying with such requirements7 during which such failure was ongoing4 ,such amount shall not exceed-- 7,i7 in the case of a specified hospital with #cj or fewer beds1 #cjj per day 7or1 in the case of such a hospital that has been noncompliant with such requirements for a #a-year period or longer1 beginning with the first day following such #a-year period1 #djj per day72 7,,ii7 in the case of a specified hospital with more than #cj beds but fewer than #aja beds1 #ab4ej per bed per day 7or1 in the case of such a hospital that has been noncompliant with such requirements for a #a-year period or longer1 beginning with the first day following such #a-year period1 #ae per bed per day72 7,,iii7 in the case of a specified hospital with more than #ajj beds but fewer than #bja beds1 #ag4ej per bed per day 7or1 in the case of such a hospital that has been noncompliant with such requirements for a #a-year period or longer1 beginning with the first day following such #a-year period1 #bj per bed per day72 7,,iv7 in the case of a specified hospital with more than #bjj beds but fewer than #eja beds1 #bj per bed per day 7or1 in the case of such a hospital that has been noncompliant with such requirements for a #a-year period or longer1 beginning with the first day following such #a-year period1 #be per bed per day72 and 7,v7 in the case of a specified hospital with more than #ejj beds1 #be per bed per day 7or1 in the case of such a hospital that has been noncompliant with such requirements for a #a-year period or longer1 beginning with the first day following such #a-year period1 #ce per bed per day74 7ii7 ,increase authority ,in applying this subparagraph with respect to violations occurring in #bjbg or a subsequent year1 the ,secretary may through notice and comment rulemaking increase-- 7,i7 the limitation on the per day amount of any penalty applicable to a specified hospital under clause 7i77,i72 7,,ii7 the limitations on the per bed per day amount of any penalty applicable under any of subclauses 7,,ii7 through 7,v7 of clause 7i72 and 7,,iii7 the amounts specified in clause 7iii77,,ii74 7iii7 ,persistent noncompliance 7,i7 ,in general ,in the case of a specified hospital 7other than a specified hospital with #cj or fewer beds7 that the ,secretary has determined to be knowingly and willfully noncompliant with the provisions of this subsection two or more times during a #a-year period1 the ,secretary may increase any penalty otherwise applicable under this subparagraph by the amount specified in subclause 7,,ii7 with respect to such hospital and may require such hospital to complete such additional corrective actions plans as the ,secretary may specify4 7,,ii7 ,specified amount ,for purposes of subclause 7,i71 the amount specified in this subclause is1 with respect to a specified hospital-- 7aa7 with more than #cj beds but fewer than #aja beds1 an amount that is not less than #ejj1jjj and not more than #a1jjj1jjj2 7bb7 with more than #ajj beds but fewer than #cja beds1 an amount that is greater than #a1jjj1jjj and not more than #b1jjj1jjj2 7cc7 with more than #cjj beds but fewer than #eja beds1 an amount that is greater than #b1jjj1jjj and not more than #d1jjj1jjj2 and 7dd7 with more than #ejj beds1 and amount that is not less than #e1jjj1jjj and not more than #aj1jjj1jjj4 7iv7 ,authority to waive or reduce penalty 7,i7 ,in general ,subject to subclause 7,,ii71 the ,secretary may waive any penalty1 or reduce any penalty by not more than #ge percent1 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 hospital4 7,,ii7 ,limitation on application ,the ,secretary may not elect to waive a penalty under subclause 7,i7 with respect to a specified hospital more than once in a #f-year period and may not elect to reduce such a penalty with respect to such a hospital more than once in such a period4 ,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 #f-year period4 7v7 ,provision of technical assistance ,the ,secretary shall1 to the extent practicable1 provide technical assistance relating to compliance with the provisions of this subsection to specified hospitals requesting such assistance4 7vi7 ,application of certain provisions ,the provisions of section #aabh;,a 7other than subsections 7a7 and 7b7 of such section7 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 7a7 of such section4 7vii7 ,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 #bgah7;f7 of the ,public ,health ,service ,act for failure to comply with the provisions of such section for such period4 7,c7 ,publication of hospital price transparency information ,beginning on ,january #a1 #bjbf1 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 subsection4 ,such information shall be updated in real time and include-- 7i7 the number of reviews of compliance with this subsection undertaken by the ,secretary2 7ii7 the number of notifications described in subparagraph 7,a77i7 sent by the ,secretary2 7iii7 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 subsection2 7iv7 the amount of any civil monetary penalty imposed on such hospital under subparagraph 7,b72 7v7 whether such hospital subsequently came into compliance with this subsection2 7vi7 any waivers or reductions of penalties made pursuant to a certification by the ,secretary under subparagraph 7,b77iv71 including-- 7,i7 the name of any specified hospital that received such a waiver or reduction2 7,,ii7 the dollar amount of each such penalty so waived or reduced2 and 7,,iii7 the rationale for the granting of each such waiver or reduction2 and 7vii7 any other information as determined by the ,secretary4 7b7 ,ensuring accessibility through implementation ,in implementing the amendments made by this section1 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 7as specified by the ,secretary7 to ensure the accessibility of such charges and information to individuals with limited ,english proficiency4 ,such steps may include the hospital's provision of interpretation services or the hospital's provision of translations of charges and information4 7c7 ,definitions ,for purposes of this section3 7#a7 ,discounted cash price ,the term discounted cash price means the charge that applies to an individual who pays cash1 or cash equivalent1 for an item or service4 7#b7 ,federal health care program ,the term ,federal health care program has the meaning given such term in section #aabh;,b4 7#c7 ,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's1 as applicable1 chargemaster1 absent any discounts4 7#d7 ,group health plan2 group health insurance coverage2 individual health insurance coverage ,the terms group health plan1 group health insurance coverage1 and individual health insurance coverage have the meaning given such terms in section #bgia of the ,public ,health ,service ,act4 7#e7 ,payer-specific negotiated charge ,the term payer-specific negotiated charge means the charge that a specified hospital or provider of services or supplier1 as applicable1 has negotiated with a third party payer for an item or service4 7#f7 ,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 service4 7#g7 ,specified hospital ,the term specified hospital means a hospital 7as defined in section #ahfa7;e771 a critical access hospital 7as defined in section #ahfa7mmm77#a771 or a rural emergency hospital 7as defined in section #ahfa7kkk774 7#h7 ,third party payer ,the term third party payer means an entity that is1 by statute1 contract1 or agreement1 legally responsible for payment of a claim for a health care item or service4 4 7b7 ,,phsa 7#a7 ,in general ,section #bgah of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ah7 is amended by adding at the end the following new subsection3 7f7 ,hospital transparency requirement 7#a7 ,in general ,beginning ,january #a1 #bjbf1 each hospital shall comply with the price transparency requirement described in paragraph 7#b74 7#b7 ,requirement described 7,a7 ,in general ,for purposes of paragraph 7#a71 the price transparency requirement described in this paragraph is1 with respect to a hospital1 that such hospital1 in accordance with a method and format established by the ,secretary under subparagraph 7,c71 compile and make public 7without subscription and free of charge7 for each year-- 7i7 all of the hospital's standard charges 7including the information described in subparagraph 7,b77 for each item and service furnished by such hospital2 7ii7 information in a consumer-friendly format 7as specified by the ,secretary7-- 7,i7 on the hospital's prices 7including the information described in subparagraph 7,b77 for as many of the ,centers for ,medicare ,medicaid ,services-specified shoppable services that are furnished by the hospital1 and as many additional hospital-selected shoppable services 7or all such additional services1 if such hospital furnishes fewer than #cjj shoppable services7 as may be necessary for a combined total of at least #cjj shoppable services2 and 7,,ii7 that includes1 with respect to each ,centers for ,medicare ,medicaid ,services-specified shoppable service that is not furnished by the hospital1 an indication that such service is not so furnished2 and 7iii7 an attestation that all information made public pursuant to this subparagraph is complete and accurate4 7,b7 ,information described ,for purposes of subparagraph 7,a71 the information described in this subparagraph is1 with respect to standard charges and prices1 as applicable1 made public by a hospital1 the following3 7i7 ,a plain language description of each item or service1 accompanied by1 as applicable1 the ,healthcare ,common ,procedure ,coding ,system code1 the diagnosis-related group1 the national drug code1 current procedure terminology codes1 or other identifier used or approved by the ,centers for ,medicare ,medicaid ,services4 7ii7 ,the gross charge1 as applicable1 expressed as a dollar amount1 for each such item or service1 when provided in1 as applicable1 the inpatient setting and outpatient department setting4 7iii7 ,the discounted cash price1 as applicable1 expressed as a dollar amount1 for each such item or service when provided in1 as applicable1 the inpatient setting and outpatient department setting 7or1 in the case no discounted cash price is available for an item or service1 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 years1 expressed as a dollar amount1 as well as1 with respect to prices made public pursuant to subparagraph 7,a77ii71 a link to a consumer-friendly document that clearly explains the hospital's charity care policy that includes1 if applicable1 any sliding scale payment structure employed for determining charges for a self-pay individual74 7iv7 ,the payer-specific negotiated charges1 as applicable1 clearly associated with the name of the third party payer and plan and expressed as a dollar amount1 that apply to each such item or service when provided in1 as applicable1 the inpatient setting and outpatient department setting4 7v7 ,the de-identified maximum and minimum negotiated charges1 as applicable1 for each such item or service4 7vi7 ,any other additional information the ,secretary may require for the purpose of improving the accuracy of1 or enabling consumers to easily understand and compare1 standard charges and prices for an item or service1 except information that is duplicative of any other reporting requirement under this subsection4 ,in the case of standard charges and prices for an item or service included as part of a bundled1 per diem1 episodic1 or other similar arrangement1 the information described in this subparagraph shall be made available as determined appropriate by the ,secretary4 7,c7 ,uniform method and format ,not later than ,january #a1 #bjbf1 the ,secretary shall establish a standard1 uniform method and format for hospitals to use in compiling and making public standard charges pursuant to subparagraph 7,a77i7 and a standard1 uniform method and format for such hospitals to use in compiling and making public prices pursuant to subparagraph 7,a77ii74 ,such methods and formats-- 7i7 shall1 in the case of such method and format for making public standard charges pursuant to subparagraph 7,a77i71 ensure that such charges are made available in a machine-readable format 7or a successor technology specified by the ,secretary72 7ii7 may be similar to any template made available by the ,centers for ,medicare ,medicaid ,services as of the date of the enactment of this subparagraph2 7iii7 shall meet such standards as determined appropriate by the ,secretary in order to ensure the accessibility and usability of such charges and prices2 and 7iv7 shall be updated as determined appropriate by the ,secretary1 in consultation with stakeholders4 7#c7 ,monitoring compliance ,the ,secretary shall1 through notice and comment rulemaking and in consultation with the ,inspector ,general of the ,department of ,health and ,human ,services1 establish a process to monitor compliance with this subsection4 ,such process shall ensure that each hospital's compliance with this subsection is reviewed not less frequently than once every #c years4 7#d7 ,enforcement 7,a7 ,in general ,in the case of a hospital that fails to comply with the requirements of this subsection-- 7i7 not later than #cj days after the date on which the ,secretary determines such failure exists1 the ,secretary shall submit to such hospital a notification of such determination 7which may include1 as determined appropriate by the ,secretary1 a request for a corrective action plan to comply with such requirements72 and 7ii7 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 7i7-- 7,i7 the ,secretary shall1 not later than #de days after such notification is sent1 determine whether such hospital is in compliance with such requirements2 and 7,,ii7 if the ,secretary determines under subclause 7,i7 that such hospital is not in compliance with such requirements1 the ,secretary shall either-- 7aa7 submit to such hospital a request for a corrective action plan to comply with such requirements2 or 7bb7 if the ,secretary determines that such hospital has not taken meaningful actions to come into compliance since such notification was sent1 impose a civil monetary penalty in accordance with subparagraph 7,b74 7,b7 ,civil monetary penalty 7i7 ,in general ,in addition to any other enforcement actions or penalties that may apply under another provision of law1 a hospital that has received a request for a corrective action plan under clause 7i7 or 7ii7 of subparagraph 7,a7 and fails to comply with the requirements of this subsection by the date that is #de days after such request is made1 and a hospital with respect to which the ,secretary has made a determination described in clause 7ii77,,ii77bb7 of such subparagraph1 shall be subject to a civil monetary penalty of an amount specified by the ,secretary for each day 7beginning with the day on which the ,secretary first determined that such hospital was not complying with such requirements7 during which such failure was ongoing4 ,such amount shall not exceed-- 7,i7 in the case of a hospital with #cj or fewer beds1 #cjj per day 7or1 in the case of such a hospital that has been noncompliant with such requirements for a #a-year period or longer1 beginning with the first day following such #a-year period1 #djj per bed per day72 7,,ii7 in the case of a hospital with more than #cj beds but fewer than #aja beds1 #ab4ej per bed per day 7or1 in the case of such a hospital that has been noncompliant with such requirements for a #a-year period or longer1 beginning with the first day following such #a-year period1 #ae per bed per day72 7,,iii7 in the case of a hospital with more than #ajj beds but fewer than #bja beds1 #ag4ej per bed per day 7or1 in the case of such a hospital that has been noncompliant with such requirements for a #a-year period or longer1 beginning with the first day following such #a-year period1 #bj per bed per day72 7,,iv7 in the case of a hospital with more than #bjj beds but fewer than #eja beds1 #bj per bed per day 7or1 in the case of such a hospital that has been noncompliant with such requirements for a #a-year period or longer1 beginning with the first day following such #a-year period1 #be per bed per day72 and 7,v7 in the case of a hospital with more than #ejj beds1 #be per bed per day 7or1 in the case of such a hospital that has been noncompliant with such requirements for a #a-year period or longer1 beginning with the first day following such #a-year period1 #ce per bed per day74 7ii7 ,increase authority ,in applying this subparagraph with respect to violations occurring in #bjbg or a subsequent year1 the ,secretary may through notice and comment rulemaking increase-- 7,i7 the limitation on the per day amount of any penalty applicable to a hospital under clause 7i77,i72 7,,ii7 the limitations on the per bed per day amount of any penalty applicable under any of subclauses 7,,ii7 through 7,v7 of clause 7i72 and 7,,iii7 the amounts specified in clause 7iii77,,ii74 7iii7 ,persistent noncompliance 7,i7 ,in general ,in the case of a hospital 7other than a hospital with #cj or fewer beds7 that the ,secretary has determined to be knowingly and willfully noncompliant with the provisions of this subsection two or more times during a #a-year period1 the ,secretary may increase any penalty otherwise applicable under this subparagraph by the amount specified in subclause 7,,ii7 with respect to such hospital and may require such hospital to complete such additional corrective actions plans as the ,secretary may specify4 7,,ii7 ,specified amount ,for purposes of subclause 7,i71 the amount specified in this subclause is1 with respect to a hospital-- 7aa7 with more than #cj beds but fewer than #aja beds1 an amount that is not less than #ejj1jjj and not more than #a1jjj1jjj2 7bb7 with more than #ajj beds but fewer than #cja beds1 an amount that is greater than #a1jjj1jjj and not more than #b1jjj1jjj2 7cc7 with more than #cjj beds but fewer than #eja beds1 an amount that is greater than #b1jjj1jjj and not more than #d1jjj1jjj2 and 7dd7 with more than #ejj beds1 and amount that is not less than #e1jjj1jjj and not more than #aj1jjj1jjj4 7iv7 ,authority to waive or reduce penalty 7,i7 ,in general ,subject to subclause 7,,ii71 the ,secretary may waive any penalty1 or reduce any penalty by not more than #ge percent1 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 hospital4 7,,ii7 ,limitation on application ,the ,secretary may not elect to waive a penalty under subclause 7,i7 with respect to a hospital more than once in a #f-year period and may not elect to reduce such a penalty with respect to such a hospital more than once in such a period4 ,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 #f-year period4 7v7 ,provision of technical assistance ,the ,secretary shall1 to the extent practicable1 provide technical assistance relating to compliance with the provisions of this section to hospitals requesting such assistance4 7vi7 ,application of certain provisions ,the provisions of section #aabh;,a 7other than subsections 7a7 and 7b7 of such section7 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 7a7 of such section4 7vii7 ,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 #ahii;,c of the ,social ,security ,act for failure to comply with the provisions of such section for such period4 7,c7 ,publication of hospital price transparency information ,beginning on ,january #a1 #bjbf1 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 subsection4 ,such information shall be updated in real time and include-- 7i7 the number of reviews of compliance with this subsection undertaken by the ,secretary2 7ii7 the number of notifications described in subparagraph 7,a77i7 sent by the ,secretary2 7iii7 the identity of each hospital that was sent such a notification and a description of the nature of such hospital's noncompliance with this subsection2 7iv7 the amount of any civil monetary penalty imposed on such hospital under subparagraph 7,b72 7v7 whether such hospital subsequently came into compliance with this subsection2 7vi7 any waivers or reductions of penalties made pursuant to a certification by the ,secretary under subparagraph 7,b77iv71 including-- 7,i7 the name of any hospital that received such a waiver or reduction2 7,,ii7 the dollar amount of each such penalty so waived or reduced2 and 7,,iii7 the rationale for the granting of each such waiver or reduction2 and 7vii7 any other information as determined by the ,secretary4 7#e7 ,ensuring accessibility through implementation ,in implementing the amendments made by this section1 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 7as specified by the ,secretary7 to ensure the accessibility of such charges and information to individuals with limited ,english proficiency4 ,such steps may include the hospital's provision of interpretation services or the hospital's provision of translations of charges and information4 7#f7 ,definitions ,for purposes of this subsection3 7,a7 ,discounted cash price ,the term discounted cash price means the charge that applies to an individual who pays cash1 or cash equivalent1 for a hospital-furnished item or service4 7,b7 ,federal health care program ,the term ,federal health care program has the meaning given such term in section #aabh;,b of the ,social ,security ,act4 7,c7 ,gross charge ,the term gross charge means the charge for an individual item or service that is reflected on a hospital's chargemaster1 absent any discounts4 7,d7 ,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 service4 7,e7 ,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 service4 7,f7 ,third party payer ,the term third party payer means an entity that is1 by statute1 contract1 or agreement1 legally responsible for payment of a claim for a health care item or service4 4 7#b7 ,conforming amendments ,section #bgah of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ah7 is amended-- 7,a7 in subsection 7b77#c71 by inserting 7other than the provisions of subsection 7f77 after this section2 and 7,b7 in subsection 7e71 by adding at the end the following new sentence3 ,the preceding provisions of this subsection shall not apply beginning on ,january #a1 #bjbf44 7#c7 ,effective date ,the amendments made by this subsection shall apply beginning ,january #a1 #bjbf4 7c7 ,accessibility through implementation ,in implementing the amendments made by this section1 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 7as specified by the ,secretary7 to ensure the accessibility of such charges and information to individuals with limited ,english proficiency4 ,such steps may include the hospital's provision of interpretation services or the hospital's provision of translations of charges and information4 #ajb4 ,clinical diagnostic laboratory test price transparency ,section #ahdf of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#b7 is amended-- 7#a7 in the header1 by inserting and additional requirements after sanctions2 and 7#b7 by adding at the end the following new subsection3 7c7 ,price transparency requirement 7#a7 ,in general ,beginning ,january #a1 #bjbf1 any applicable laboratory that receives payment under this title for furnishing any specified clinical diagnostic laboratory test under this title shall-- 7,a7 make publicly available on an internet website the information described in paragraph 7#b7 with respect to each such specified clinical diagnostic laboratory test that such laboratory so furnishes2 and 7,b7 ensure that such information is updated not less frequently than annually4 7#b7 ,information described ,for purposes of paragraph 7#a71 the information described in this paragraph is1 with respect to an applicable laboratory and a specified clinical diagnostic laboratory test1 the following3 7,a7 ,the discounted cash price for such test 7or1 if no such price exists1 the gross charge for such test74 7,b7 ,the deidentified minimum payer-specific negotiated charge between such laboratory and any third party payer for such test4 7,c7 ,the deidentified maximum payer-specific negotiated charge between such laboratory and any third party payer for such test4 7#c7 ,uniform method and format ,not later than ,january #a1 #bjbf1 the ,secretary shall establish a standard1 uniform method and format for applicable laboratories to use in compiling and making public information pursuant to paragraph 7#a74 ,such method and format-- 7,a7 may be similar to any template made available by the ,centers for ,medicare ,medicaid ,services 7as described in section #ahii;,c7a77#b77;,c77ii772 7,b7 shall meet such standards as determined appropriate by the ,secretary in order to ensure the accessibility and usability of such information2 and 7,c7 shall be updated as determined appropriate by the ,secretary1 in consultation with stakeholders4 7#d7 ,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 7#a7 shall include the price or rate 7as applicable7 for any ancillary item or service 7such as specimen collection services7 that would normally be furnished by such laboratory as part of such test1 as specified by the ,secretary4 7#e7 ,enforcement 7,a7 ,in general ,in the case that the ,secretary determines that an applicable laboratory is not in compliance with paragraph 7#a7-- 7i7 not later than #cj days after such determination1 the ,secretary shall notify such laboratory of such determination2 and 7ii7 if such laboratory continues to fail to comply with such paragraph after the date that is #ij days after such notification is sent1 the ,secretary may impose a civil monetary penalty in an amount not to exceed #cjj for each 7beginning with the day on which the ,secretary first determined that such laboratory was failing to comply with such paragraph7 during which such failure is ongoing4 7,b7 ,increase authority ,in applying this paragraph with respect to violations occurring in #bjbg or a subsequent year1 the ,secretary may through notice and comment rulemaking increase the per day limitation on civil monetary penalties under subparagraph 7,a77ii74 7,c7 ,application of certain provisions ,the provisions of section #aabh;,a 7other than subsections 7a7 and 7b7 of such section7 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 7a7 of such section4 7#f7 ,provision of technical assistance ,the ,secretary shall1 to the extent practicable1 provide technical assistance relating to compliance with the provisions of this subsection to applicable laboratories requesting such assistance4 7#g7 ,definitions ,in this subsection3 7,a7 ,applicable laboratory ,the term applicable laboratory has the meaning given such term in section #dad4ejb1 of title #db1 ,code of ,federal ,regulations 7or a successor regulation71 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 #ahii;,c or section #bgah7;f7 of the ,public ,health ,service ,act4 7,b7 ,discounted cash price ,the term discounted cash price means the charge that applies to an individual who pays cash1 or cash equivalent1 for an item or service4 7,c7 ,gross charge ,the term gross charge means the charge for an individual item or service that is reflected on an applicable laboratory's chargemaster1 absent any discounts4 7,d7 ,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 service4 7,e7 ,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 7as described in section #ahii;,c7a77#b77;,a77ii77,i771 other than such a test that is only available to be furnished by a single provider of services or supplier4 7,f7 ,third party payer ,the term third party payer means an entity that is1 by statute1 contract1 or agreement1 legally responsible for payment of a claim for a health care item or service4 4 #ajc4 ,imaging price transparency ,section #ahii;,c of the ,social ,security ,act1 as added by section #aja1 is amended-- 7#a7 by redesignating subsection 7b7 as subsection 7c72 7#b7 by inserting after subsection 7a7 the following new subsection3 7b7 ,imaging services price transparency 7#a7 ,in general ,beginning ,january #a1 #bjbh1 each provider of services and supplier that receives payment under this title for furnishing a specified imaging service1 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 #ahii;,c or section #bgah7;f7 of the ,public ,health ,service ,act1 shall-- 7,a7 make publicly available 7in accordance with paragraph 7#c77 on an internet website the information described in paragraph 7#b7 with respect to each such service that such provider of services or supplier furnishes2 and 7,b7 ensure that such information is updated not less frequently than annually4 7#b7 ,information described ,for purposes of paragraph 7#a71 the information described in this paragraph is1 with respect to a provider of services or supplier and a specified imaging service1 the following3 7,a7 ,the discounted cash price for such service 7or1 if no such price exists1 the gross charge for such service74 7,b7 ,if required by the ,secretary1 the deidentified minimum payer-specific negotiated charge for such service and the deidentified maximum payer-specific negotiated charge for such service4 7#c7 ,uniform method and format ,not later than ,january #a1 #bjbh1 the ,secretary shall establish a standard1 uniform method and format for providers of services and suppliers to use in making public information described in paragraph 7#b74 ,any such method and format-- 7,a7 may be similar to any template made available by the ,centers for ,medicare ,medicaid ,services 7as described in section #ahii;,c7a77#b77;,c77ii772 7,b7 shall meet such standards as determined appropriate by the ,secretary in order to ensure the accessibility and usability of such information2 and 7,c7 shall be updated as determined appropriate by the ,secretary1 in consultation with stakeholders4 7#d7 ,monitoring compliance ,the ,secretary shall1 through notice and comment rulemaking and in consultation with the ,inspector ,general of the ,department of ,health and ,human ,services1 establish a process to monitor compliance with this subsection4 7#e7 ,enforcement 7,a7 ,in general ,in the case that the ,secretary determines that a provider of services or supplier is not in compliance with paragraph 7#a7-- 7i7 not later than #cj days after such determination1 the ,secretary shall notify such provider or supplier of such determination2 7ii7 upon request of the ,secretary1 such provider or supplier shall submit to the ,secretary1 not later than #de days after the date of such request1 a corrective action plan to comply with such paragraph2 and 7iii7 if such provider or supplier continues to fail to comply with such paragraph after the date that is #ij days after such notification is sent 7or1 in the case of such a provider or supplier that has submitted a corrective action plan described in clause 7ii7 in response to a request so described1 after the date that is #ij days after such submission71 the ,secretary may impose a civil monetary penalty in an amount not to exceed #cjj for each day 7beginning with the day on which the ,secretary first determined that such provider or supplier was failing to comply with such paragraph7 during which such failure to comply or failure to submit is ongoing4 7,b7 ,increase authority ,in applying this paragraph with respect to violations occurring in #bjbi or a subsequent year1 the ,secretary may through notice and comment rulemaking increase the amount of the civil monetary penalty under subparagraph 7,a77iii74 7,c7 ,application of certain provisions ,the provisions of section #aabh;,a 7other than subsections 7a7 and 7b7 of such section7 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 7a7 of such section4 7,d7 ,authority to waive or reduce penalty 7i7 ,in general ,subject to clause 7ii71 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 supplier4 7ii7 ,limitation ,the ,secretary may not elect to waive or reduce a penalty under clause 7i7 with respect to a specific provider of services or supplier more than #c times4 7,e7 ,provision of technical assistance ,the ,secretary shall1 to the extent practicable1 provide technical assistance relating to compliance with the provisions of this subsection to providers of services and suppliers requesting such assistance4 7,f7 ,clarification of nonapplicability of other enforcement provisions ,notwithstanding any other provision of this title1 this paragraph shall be the sole means of enforcing the provisions of this subsection4 2 and 7#c7 in subsection 7c71 as so redesignated by paragraph 7#a7-- 7,a7 by redesignating paragraph 7#h7 as paragraph 7#i72 and 7,b7 by inserting after paragraph 7#g7 the following new paragraph3 7#h7 ,specified imaging service the term specified imaging service means an imaging service that is a ,centers for ,medicare ,medicaid ,services-specified shoppable service 7as described in subsection 7a77#b77;,a77ii77,i774 4 #ajd4 ,ambulatory surgical center price transparency ,section #ahcd of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7 is amended by adding at the end the following new subsection3 7aa7 ,ambulatory surgical center price transparency 7#a7 ,in general ,beginning ,january #a1 #bjbf1 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 7#b74 7#b7 ,requirement described 7,a7 ,in general ,for purposes of paragraph 7#a71 the price transparency requirement described in this subsection is1 with respect to an ambulatory surgical center1 that such surgical center in accordance with a method and format established by the ,secretary under subparagraph 7,c71 compile and make public 7without subscription and free of charge71 for each year-- 7i7 all of the ambulatory surgical center's standard charges 7including the information described in subparagraph 7,b77 for each item and service furnished by such surgical center2 7ii7 information on the ambulatory surgical center's prices 7including the information described in subparagraph 7,b77 for as many of the ,centers for ,medicare ,medicaid ,services-specified shoppable services that are furnished by such surgical center1 and as many additional ambulatory surgical center-selected shoppable services 7or all such additional services1 if such surgical center furnishes fewer than #cjj shoppable services7 as may be necessary for a combined total of at least #cjj shoppable services2 and 7iii7 with respect to each ,centers for ,medicare ,medicaid ,services-specified shoppable service that is not furnished by the ambulatory surgical center1 an indication that such service is not so furnished4 7,b7 ,information described ,for purposes of subparagraph 7,a71 the information described in this subparagraph is1 with respect to standard charges and prices 7as applicable7 made public by an ambulatory surgical center1 the following3 7i7 ,a plain language description of each item or service1 accompanied by1 as applicable1 the ,healthcare ,common ,procedure ,coding ,system code1 the diagnosis-related group1 the national drug code1 or other identifier used or approved by the ,centers for ,medicare ,medicaid ,services4 7ii7 ,the gross charge1 as applicable1 expressed as a dollar amount1 for each such item or service4 7iii7 ,the discounted cash price1 as applicable1 expressed as a dollar amount1 for each such item or service 7or1 in the case no discounted cash price is available for an item or service1 the median cash price charged to self-pay individuals for such item or service for the previous three years1 expressed as a dollar amount74 7iv7 ,the current payer-specific negotiated charges1 clearly associated with the name of the third party payer and plan and expressed as a dollar amount1 that applies to each such item or service4 7v7 ,the de-identified maximum and minimum negotiated charges1 as applicable1 for each such item or service4 7vi7 ,any other additional information the ,secretary may require for the purpose of improving the accuracy of1 or enabling consumers to easily understand and compare1 standard charges and prices for an item or service1 except information that is duplicative of any other reporting requirement under this subsection4 7,c7 ,uniform method and format ,not later than ,january #a1 #bjbf1 the ,secretary shall establish a standard1 uniform method and format for ambulatory surgical centers to use in making public standard charges and a standard1 uniform method and format for such centers to use in making public prices pursuant to subparagraph 7,a74 ,any such method and format-- 7i7 shall1 in the case of such charges made public by an ambulatory surgical center1 ensure that such charges are made available in a machine-readable format 7or successor technology72 7ii7 may be similar to any template made available by the ,centers for ,medicare ,medicaid ,services as of the date of the enactment of this paragraph2 7iii7 shall meet such standards as determined appropriate by the ,secretary in order to ensure the accessibility and usability of such charges and prices2 and 7iv7 shall be updated as determined appropriate by the ,secretary1 in consultation with stakeholders4 7#c7 ,monitoring compliance ,the ,secretary shall1 through notice and comment rulemaking and in consultation with the ,inspector ,general of the ,department of ,health and ,human ,services1 establish a process to monitor compliance with this subsection4 ,such process shall ensure that each ambulatory surgical center's compliance with this subsection is reviewed not less frequently than once every #c years4 7#d7 ,enforcement 7,a7 ,in general ,in the case of an ambulatory surgical center that fails to comply with the requirements of this subsection-- 7i7 the ,secretary shall notify such ambulatory surgical center of such failure not later than #cj days after the date on which the ,secretary determines such failure exists2 and 7ii7 upon request of the ,secretary1 the ambulatory surgical center shall submit to the ,secretary1 not later than #de days after the date of such request1 a corrective action plan to comply with such requirements4 7,b7 ,civil monetary penalty 7i7 ,in general ,in addition to any other enforcement actions or penalties that may apply under another provision of law1 an ambulatory surgical center that has received a notification under subparagraph 7,a77i7 and fails to comply with the requirements of this subsection by the date that is #ij days after such notification 7or1 in the case of an ambulatory surgical center that has submitted a corrective action plan described in subparagraph 7,a77ii7 in response to a request so described1 by the date that is #ij days after such submission7 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 7not to exceed #cjj per day74 7ii7 ,increase authority ,in applying this subparagraph with respect to violations occurring in #bjbg or a subsequent year1 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 7i74 7iii7 ,application of certain provisions ,the provisions of section #aabh;,a 7other than subsections 7a7 and 7b7 of such section7 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 7a7 of such section4 7iv7 ,authority to waive or reduce penalty 7,i7 ,in general ,subject to subclause 7,,ii71 the ,secretary may waive any penalty1 or reduce any penalty by not more than #ge percent1 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 center4 7,,ii7 ,limitation on application ,the ,secretary may not elect to waive a penalty under subclause 7,i7 with respect to an ambulatory surgical center more than once in a #f-year period and may not elect to reduce such a penalty with respect to such a surgical center more than once in such a period4 ,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 #f-year period4 7#e7 ,definitions ,for purposes of this section3 7,a7 ,discounted cash price ,the term discounted cash price means the charge that applies to an individual who pays cash1 or cash equivalent1 for a item or service furnished by an ambulatory surgical center4 7,b7 ,federal health care program ,the term ,federal health care program has the meaning given such term in section #aabh;,b4 7,c7 ,gross charge ,the term gross charge means the charge for an individual item or service that is reflected on an ambulatory surgical center's chargemaster1 absent any discounts4 7,d7 ,group health plan2 group health insurance coverage2 individual health insurance coverage ,the terms group health plan1 group health insurance coverage1 and individual health insurance coverage have the meaning given such terms in section #bgia of the ,public ,health ,service ,act4 7,e7 ,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 service4 7,f7 ,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 service4 7,g7 ,third party payer ,the term third party payer means an entity that is1 by statute1 contract1 or agreement1 legally responsible for payment of a claim for a health care item or service4 4 #aje4 ,health coverage price transparency 7a7 ,price transparency requirements 7#a7 ,,irc 7,a7 ,in general ,section #ihai of the ,internal ,revenue ,code of #aihf is amended to read as follows3 #ihai4 ,transparency in coverage 7a7 ,cost-sharing transparency 7#a7 ,in general ,for plan years beginning on or after ,january #a1 #bjbf1 a group health plan shall permit a participant or beneficiary to learn the amount of cost-sharing 7including deductibles1 copayments1 and coinsurance7 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 beneficiary4 ,at a minimum1 such information shall include the information specified in paragraph 7#b7 and shall be made available to such participant or beneficiary through a self-service tool that meets the requirements of paragraph 7#c7 or1 at the option of such participant or beneficiary1 through a paper disclosure or phone or other electronic disclosure 7as selected by such participant or beneficiary and provided at no cost to such participant or beneficiary7 that meets such requirements as the ,secretary may specify4 7#b7 ,specified information ,for purposes of paragraph 7#a71 the information specified in this paragraph is1 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 plan1 the following3 7,a7 ,if such provider is a participating provider with respect to such item or service1 the in-network rate 7as defined in subsection 7c77 for such item or service4 7,b7 ,if such provider is not a participating provider with respect to such item or service1 the maximum allowed amount or other dollar amount that such plan or coverage will recognize as payment for such item or service1 along with a notice that such participant or beneficiary may be liable for additional charges4 7,c7 ,the estimated amount of cost sharing 7including deductibles1 copayments1 and coinsurance7 that the participant or beneficiary will incur for such item or service 7which1 in the case such item or service is to be furnished by a provider described in subparagraph 7,b71 shall be calculated using the maximum allowed amount or other dollar amount described in such subparagraph74 7,d7 ,the amount the participant or beneficiary has already accumulated with respect to any deductible or out of pocket maximum under the plan 7broken down1 in the case separate deductibles or maximums apply to separate participants and beneficiaries enrolled in the plan1 by such separate deductibles or maximums1 in addition to any cumulative deductible or maximum74 7,e7 ,in the case such plan imposes any frequency or volume limitations with respect to such item or service 7excluding medical necessity determinations71 the amount that such participant or beneficiary has accrued towards such limitation with respect to such item or service4 7,f7 ,any prior authorization1 concurrent review1 step therapy1 fail first1 or similar requirements applicable to coverage of such item or service under such plan4 7,g7 ,any shared savings 7such as any credit1 payment1 or other benefit provided by such plan7 available to the participant or beneficiary with respect to such item or service furnished by such provider known at the time such request is made4 7#c7 ,self-service tool ,for purposes of paragraph 7#a71 a self-service tool established by a group health plan meets the requirements of this paragraph if such tool-- 7,a7 is based on an ,internet website 7or successor technology specified by the ,secretary72 7,b7 provides for real-time responses to requests described in paragraph 7#a72 7,c7 is updated in a manner such that information provided through such tool is timely and accurate at the time such request is made2 7,d7 allows such a request to be made with respect to an item or service furnished by-- 7i7 a specific provider that is a participating provider with respect to such item or service2 or 7ii7 all providers that are participating providers with respect to such item or service2 7,e7 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 service2 and 7,f7 meets any other requirement determined appropriate by the ,secretary to ensure the accessibility and usability of information provided through such tool4 ,the ,secretary may require such tool1 as a condition of complying with subparagraph 7,e71 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 services4 7b7 ,rate and payment information 7#a7 ,in general ,for plan years beginning on or after ,january #a1 #bjbf1 each group health plan 7other than a grandfathered health plan 7as defined in section #abea7;e7 of the ,patient ,protection and ,affordable ,care ,act77 shall1 for each month1 not later than the tenth day of such month1 make available to the public the rate and payment information described in paragraph 7#b7 in accordance with paragraph 7#c74 7#b7 ,rate and payment information described ,for purposes of paragraph 7#a71 the rate and payment information described in this paragraph is1 with respect to a group health plan1 the following3 7,a7 ,with respect to each item or service 7other than a drug7 for which benefits are available under such plan1 the in-network rate 7expressed as a dollar amount7 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 service4 7,b7 ,with respect to each drug 7identified by national drug code7 for which benefits are available under such plan-- 7i7 the in-network rate 7expressed as a dollar amount7 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 drug2 and 7ii7 the average amount paid by such plan 7net of rebates1 discounts1 and price concessions7 for such drug dispensed or administered during the #ij-;day period beginning #ahj days before such date of publication to each provider that was a participating provider with respect to such drug1 broken down by each such provider1 other than such an amount paid to a provider that1 during such period1 submitted fewer than #bj claims for such drug to such plan4 7,c7 ,with respect to each item or service for which benefits are available under such plan1 the amount billed1 and the amount allowed by the plan1 for each such item or service furnished during the #ij-;day period specified in subparagraph 7,b7 by a provider that was not a participating provider with respect to such item or service1 broken down by each such provider4 7#c7 ,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 7and any successor technology1 such as application program interface technology1 determined appropriate by the ,secretary7 corresponding to the information described in each of subparagraphs 7,a7 through 7,c7 of paragraph 7#b7 that meet such requirements as specified by the ,secretary through subregulatory guidance4 ,such requirements shall ensure that such files are limited to an appropriate size1 do not include disclosure of unnecessary duplicative information contained in other files made available under this subsection1 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 coverage1 and are accessible to individuals at no cost and without the need to establish a user account or provide other credentials4 7#d7 ,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 7#b7 in files submitted in accordance with paragraph 7#c74 ,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 sentence4 7#e7 ,summary ,for each plan year beginning on or after ,january #a1 #bjbf1 each group health plan shall make public a data file1 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 ,secretary1 containing a summary of all rate and payment information made public by such plan with respect to such plan during such plan year4 ,such file shall include the following3 7,a7 ,the mean1 median1 and interquartile range of the in-network rate1 and the amount allowed for an item or service when not furnished by a participating provider1 in effect as of the first day of such plan year for each item or service 7identified by payer identifier approved or used by the ,centers for ,medicare ,medicaid ,services7 for which benefits are available under the plan1 broken down by the type of provider furnishing the item or service and by the geographic area in which such item or service is furnished4 7,b7 ,trends in payment rates for such items and services over such plan year1 including an identification of instances in which such rates have increased1 decreased1 or remained the same4 7,c7 ,the name of such plan1 a description of the type of network of participating providers used by such plan1 and a description of whether such plan is self-insured or fully-insured4 7,d7 ,for each item or service which is paid as part of a bundled rate-- 7i7 a description of the formulae1 pricing methodologies1 or other information used to calculate the payment rate for such bundle2 and 7ii7 a list of the items and services included in such bundle4 7,e7 ,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 rate1 capitated payment rate1 or other alternative payment model4 7#f7 ,attestation ,each group health plan shall post1 along with rate and payment information made public by such plan1 an attestation that such information is complete and accurate4 7c7 ,accessibility ,a group health plan shall take reasonable steps 7as specified by the ,secretary7 to ensure that information provided in response to a request described in subsection 7a71 and rate and payment information made public under subsection 7b71 is provided in plain1 easily understandable language and that interpretation1 translations1 and assistive services are provided to those with limited ,english proficiency and those with disabilities4 7d7 ,definitions ,in this section3 7#a7 ,participating provider ,the term participating provider means1 with respect to an item or service and a group health plan1 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 plan1 respectively1 for furnishing such item or service under the plan1 and includes facilities1 respectively4 7#b7 ,provider ,the term provider includes a health care facility4 7#c7 ,in-network rate ,the term in-network rate means1 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 service1 the contracted rate 7reflected as a dollar amount7 in effect between such plan and such provider for such item or service1 regardless of whether such rate is calculated based on a set amount1 a fee schedule1 or an amount derived from another amount1 or a formula1 or other method4 4 7,b7 ,clerical amendment ,the item relating to section #ihai of the table of sections for subchapter ,b of chapter #ajj of the ,internal ,revenue ,code of #aihf is amended to read as follows3 ,sec4 #ihai4 ,transparency in coverage4 4 7#b7 ,,phsa ,section #bgii;,a-#d of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#aad7 is amended to read as follows3 #bgii;,a-#d4 ,transparency in coverage 7a7 ,cost-sharing transparency 7#a7 ,in general ,for plan years beginning on or after ,january #a1 #bjbf1 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 7including deductibles1 copayments1 and coinsurance7 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 individual4 ,at a minimum1 such information shall include the information specified in paragraph 7#b7 and shall be made available to such individual through a self-service tool that meets the requirements of paragraph 7#c7 or1 at the option of such individual1 through a paper disclosure or phone or other electronic disclosure 7as selected by such individual and provided at no cost to such individual7 that meets such requirements as the ,secretary may specify4 7#b7 ,specified information ,for purposes of paragraph 7#a71 the information specified in this paragraph is1 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 coverage1 the following3 7,a7 ,if such provider is a participating provider with respect to such item or service1 the in-network rate 7as defined in subsection 7c77 for such item or service4 7,b7 ,if such provider is not a participating provider with respect to such item or service1 the maximum allowed amount or other dollar amount that such plan or coverage will recognize as payment for such item or service1 along with a notice that such individual may be liable for additional charges4 7,c7 ,the estimated amount of cost sharing 7including deductibles1 copayments1 and coinsurance7 that the individual will incur for such item or service 7which1 in the case such item or service is to be furnished by a provider described in subparagraph 7,b71 shall be calculated using the maximum allowed amount or other dollar amount described in such subparagraph74 7,d7 ,the amount the individual has already accumulated with respect to any deductible or out of pocket maximum under the plan or coverage 7broken down1 in the case separate deductibles or maximums apply to separate individuals enrolled in the plan or coverage1 by such separate deductibles or maximums1 in addition to any cumulative deductible or maximum74 7,e7 ,in the case such plan imposes any frequency or volume limitations with respect to such item or service 7excluding medical necessity determinations71 the amount that such individual has accrued towards such limitation with respect to such item or service4 7,f7 ,any prior authorization1 concurrent review1 step therapy1 fail first1 or similar requirements applicable to coverage of such item or service under such plan or coverage4 7,g7 ,any shared savings 7such as any credit1 payment1 or other benefit provided by such plan or issuer7 available to the individual with respect to such item or service furnished by such provider known at the time such request is made4 7#c7 ,self-service tool ,for purposes of paragraph 7#a71 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-- 7,a7 is based on an internet website 7or successor technology specified by the ,secretary72 7,b7 provides for real-time responses to requests described in paragraph 7#a72 7,c7 is updated in a manner such that information provided through such tool is timely and accurate at the time such request is made2 7,d7 allows such a request to be made with respect to an item or service furnished by-- 7i7 a specific provider that is a participating provider with respect to such item or service2 or 7ii7 all providers that are participating providers with respect to such item or service2 7,e7 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 service2 and 7,f7 meets any other requirement determined appropriate by the ,secretary to ensure the accessibility and usability of information provided through such tool4 ,the ,secretary may require such tool1 as a condition of complying with subparagraph 7,e71 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 services4 7b7 ,rate and payment information 7#a7 ,in general ,for plan years beginning on or after ,january #a1 #bjbf1 each group health plan and health insurance issuer offering group or individual health insurance coverage 7other than a grandfathered health plan 7as defined in section #abea7;e7 of the ,patient ,protection and ,affordable ,care ,act77 shall1 for each month1 not later than the tenth day of such month1 make available to the public the rate and payment information described in paragraph 7#b7 in accordance with paragraph 7#c74 7#b7 ,rate and payment information described ,for purposes of paragraph 7#a71 the rate and payment information described in this paragraph is1 with respect to a group health plan or group or individual health insurance coverage1 the following3 7,a7 ,with respect to each item or service 7other than a drug7 for which benefits are available under such plan or coverage1 the in-network rate 7expressed as a dollar amount7 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 service4 7,b7 ,with respect to each drug 7identified by national drug code7 for which benefits are available under such plan or coverage-- 7i7 the in-network rate 7expressed as a dollar amount7 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 drug2 and 7ii7 the average amount paid by such plan 7net of rebates1 discounts1 and price concessions7 for such drug dispensed or administered during the #ij-;day period beginning #ahj days before such date of publication to each provider that was a participating provider with respect to such drug1 broken down by each such provider1 other than such an amount paid to a provider that1 during such period1 submitted fewer than #bj claims for such drug to such plan or coverage4 7,c7 ,with respect to each item or service for which benefits are available under such plan or coverage1 the amount billed1 and the amount allowed by the plan1 for each such item or service furnished during the #ij-;day period specified in subparagraph 7,b7 by a provider that was not a participating provider with respect to such item or service1 broken down by each such provider4 7#c7 ,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 7and any successor technology1 such as application program interface technology1 determined appropriate by the ,secretary7 corresponding to the information described in each of subparagraphs 7,a7 through 7,c7 of paragraph 7#b7 that meet such requirements as specified by the ,secretary through subregulatory guidance4 ,such requirements shall ensure that such files are limited to an appropriate size1 do not include disclosure of unnecessary duplicative information contained in other files made available under this subsection1 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 coverage1 and are accessible to individuals at no cost and without the need to establish a user account or provide other credentials4 7#d7 ,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 7#b7 in files submitted in accordance with paragraph 7#c74 ,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 sentence4 7#e7 ,summary ,for each plan year beginning on or after ,january #a1 #bjbf1 each group health plan and health insurance issuer offering group or individual health insurance coverage shall make public a data file1 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 ,secretary1 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 year4 ,such file shall include the following3 7,a7 ,the mean1 median1 and interquartile range of the in-network rate1 and the amount allowed for an item or service when not furnished by a participating provider1 in effect as of the first day of such plan year for each item or service 7identified by payer identifier approved or used by the ,centers for ,medicare ,medicaid ,services7 for which benefits are available under the plan or coverage1 broken down by the type of provider furnishing the item or service and by the geographic area in which such item or service is furnished4 7,b7 ,trends in payment rates for such items and services over such plan year1 including an identification of instances in which such rates have increased1 decreased1 or remained the same4 7,c7 ,the name of such plan1 a description of the type of network of participating providers used by such plan or coverage1 and1 in the case of a group health plan1 a description of whether such plan is self-insured or fully-insured4 7,d7 ,for each item or service which is paid as part of a bundled rate-- 7i7 a description of the formulae1 pricing methodologies1 or other information used to calculate the payment rate for such bundle2 and 7ii7 a list of the items and services included in such bundle4 7,e7 ,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 rate1 capitated payment rate1 or other alternative payment model4 7#f7 ,attestation ,each group health plan and health insurance issuer offering group or individual health insurance coverage shall post1 along with rate and payment information made public by such plan or issuer1 an attestation that such information is complete and accurate4 7c7 ,accessibility ,a group health plan and a health insurance issuer offering group or individual health insurance coverage shall take reasonable steps 7as specified by the ,secretary7 to ensure that information provided in response to a request described in subsection 7a71 and rate and payment information made public under subsection 7b71 is provided in plain1 easily understandable language and that interpretation1 translations1 and assistive services are provided to those with limited ,english proficiency and those with disabilities4 7d7 ,definitions ,in this section3 7#a7 ,participating provider ,the term participating provider means1 with respect to an item or service and a group health plan or health insurance issuer offering group or individual health insurance coverage1 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 issuer1 respectively1 for furnishing such item or service under the plan or coverage1 and includes facilities1 respectively4 7#b7 ,provider ,the term provider includes a health care facility4 7#c7 ,in-network rate ,the term in-network rate means1 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 service1 the contracted rate 7reflected as a dollar amount7 in effect between such plan or coverage and such provider for such item or service1 regardless of whether such rate is calculated based on a set amount1 a fee schedule1 or an amount derived from another amount1 or a formula1 or other method4 4 7#c7 ,,erisa 7,a7 ,in general ,section #gai of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aahe;h7 is amended to read as follows3 #gai4 ,transparency in coverage 7a7 ,cost-,sharing transparency 7#a7 ,in general ,for plan years beginning on or after ,january #a1 #bjbf1 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 7including deductibles1 copayments1 and coinsurance7 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 beneficiary4 ,at a minimum1 such information shall include the information specified in paragraph 7#b7 and shall be made available to such participant or beneficiary through a self-service tool that meets the requirements of paragraph 7#c7 or1 at the option of such participant or beneficiary1 through a paper disclosure or phone or other electronic disclosure 7as selected by such participant or beneficiary and provided at no cost to such participant or beneficiary7 that meets such requirements as the ,secretary may specify4 7#b7 ,specified information ,for purposes of paragraph 7#a71 the information specified in this paragraph is1 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 coverage1 the following3 7,a7 ,if such provider is a participating provider with respect to such item or service1 the in-network rate 7as defined in subsection 7c77 for such item or service4 7,b7 ,if such provider is not a participating provider with respect to such item or service1 the maximum allowed amount or other dollar amount that such plan or coverage will recognize as payment for such item or service1 along with a notice that such participant or beneficiary may be liable for additional charges4 7,c7 ,the estimated amount of cost-sharing 7including deductibles1 copayments1 and coinsurance7 that the participant or beneficiary will incur for such item or service 7which1 in the case such item or service is to be furnished by a provider described in subparagraph 7,b71 shall be calculated using the maximum allowed amount or other dollar amount described in such subparagraph74 7,d7 ,the amount the participant or beneficiary has already accumulated with respect to any deductible or out of pocket maximum under the plan or coverage 7broken down1 in the case separate deductibles or maximums apply to separate participants and beneficiaries enrolled in the plan or coverage1 by such separate deductibles or maximums1 in addition to any cumulative deductible or maximum74 7,e7 ,in the case such plan imposes any frequency or volume limitations with respect to such item or service 7excluding medical necessity determinations71 the amount that such participant or beneficiary has accrued towards such limitation with respect to such item or service4 7,f7 ,any prior authorization1 concurrent review1 step therapy1 fail first1 or similar requirements applicable to coverage of such item or service under such plan or coverage4 7,g7 ,any shared savings 7such as any credit1 payment1 or other benefit provided by such plan or issuer7 available to the participant or beneficiary with respect to such item or service furnished by such provider known at the time such request is made4 7#c7 ,self-service tool ,for purposes of paragraph 7#a71 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-- 7,a7 is based on an internet website 7or successor technology specified by the ,secretary72 7,b7 provides for real-time responses to requests described in paragraph 7#a72 7,c7 is updated in a manner such that information provided through such tool is timely and accurate at the time such request is made2 7,d7 allows such a request to be made with respect to an item or service furnished by-- 7i7 a specific provider that is a participating provider with respect to such item or service2 or 7ii7 all providers that are participating providers with respect to such item or service2 7,e7 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 service2 and 7,f7 meets any other requirement determined appropriate by the ,secretary to ensure the accessibility and usability of information provided through such tool4 ,the ,secretary may require such tool1 as a condition of complying with subparagraph 7,e71 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 services4 7b7 ,rate and payment information 7#a7 ,in general ,for plan years beginning on or after ,january #a1 #bjbf1 each group health plan and health insurance issuer offering group health insurance coverage 7other than a grandfathered health plan 7as defined in section #abea7;e7 of the ,patient ,protection and ,affordable ,care ,act77 shall1 for each month1 not later than the tenth day of such month1 make available to the public the rate and payment information described in paragraph 7#b7 in accordance with paragraph 7#c74 7#b7 ,rate and payment information described ,for purposes of paragraph 7#a71 the rate and payment information described in this paragraph is1 with respect to a group health plan or group health insurance coverage1 the following3 7,a7 ,with respect to each item or service 7other than a drug7 for which benefits are available under such plan or coverage1 the in-network rate 7expressed as a dollar amount7 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 service4 7,b7 ,with respect to each drug 7identified by national drug code7 for which benefits are available under such plan or coverage-- 7i7 the in-network rate 7expressed as a dollar amount7 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 drug2 and 7ii7 the average amount paid by such plan 7net of rebates1 discounts1 and price concessions7 for such drug dispensed or administered during the #ij-;day period beginning #ahj days before such date of publication to each provider that was a participating provider with respect to such drug1 broken down by each such provider1 other than such an amount paid to a provider that1 during such period1 submitted fewer than #bj claims for such drug to such plan or coverage4 7,c7 ,with respect to each item or service for which benefits are available under such plan or coverage1 the amount billed1 and the amount allowed by the plan1 for each such item or service furnished during the #ij-;day period specified in subparagraph 7,b7 by a provider that was not a participating provider with respect to such item or service1 broken down by each such provider4 7#c7 ,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 7and any successor technology1 such as application program interface technology1 determined appropriate by the ,secretary7 corresponding to the information described in each of subparagraphs 7,a7 through 7,c7 of paragraph 7#b7 that meet such requirements as specified by the ,secretary through subregulatory guidance4 ,such requirements shall ensure that such files are limited to an appropriate size1 do not include disclosure of unnecessary duplicative information contained in other files made available under this subsection1 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 coverage1 and are accessible to individuals at no cost and without the need to establish a user account or provide other credentials4 7#d7 ,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 7#b7 in files submitted in accordance with paragraph 7#c74 ,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 sentence4 7#e7 ,summary ,for each plan year beginning on or after ,january #a1 #bjbf1 each group health plan and health insurance issuer offering group health insurance coverage shall make public a data file1 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 ,secretary1 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 year4 ,such file shall include the following3 7,a7 ,the mean1 median1 and interquartile range of the in-network rate1 and the amount allowed for an item or service when not furnished by a participating provider1 in effect as of the first day of such plan year for each item or service 7identified by payer identifier approved or used by the ,centers for ,medicare ,medicaid ,services7 for which benefits are available under the plan or coverage1 broken down by the type of provider furnishing the item or service and by the geographic area in which such item or service is furnished4 7,b7 ,trends in payment rates for such items and services over such plan year1 including an identification of instances in which such rates have increased1 decreased1 or remained the same4 7,c7 ,the name of such plan1 a description of the type of network of participating providers used by such plan or coverage1 and1 in the case of a group health plan1 a description of whether such plan is self-insured or fully-insured4 7,d7 ,for each item or service which is paid as part of a bundled rate-- 7i7 a description of the formulae1 pricing methodologies1 or other information used to calculate the payment rate for such bundle2 and 7ii7 a list of the items and services included in such bundle4 7,e7 ,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 rate1 capitated payment rate1 or other alternative payment model4 7#f7 ,attestation ,each group health plan and health insurance issuer offering group health insurance coverage shall post1 along with rate and payment information made public by such plan or issuer1 an attestation that such information is complete and accurate4 7c7 ,accessibility ,a group health plan and a health insurance issuer offering group health insurance coverage shall take reasonable steps 7as specified by the ,secretary7 to ensure that information provided in response to a request described in subsection 7a71 and rate and payment information made public under subsection 7b71 is provided in plain1 easily understandable language and that interpretation1 translations1 and assistive services are provided to those with limited ,english proficiency and those with disabilities4 7d7 ,definitions ,in this section3 7#a7 ,participating provider ,the term participating provider means1 with respect to an item or service and a group health plan or health insurance issuer offering group or individual health insurance coverage1 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 issuer1 respectively1 for furnishing such item or service under the plan or coverage1 and includes facilities1 respectively4 7#b7 ,provider ,the term provider includes a health care facility4 7#c7 ,in-network rate ,the term in-network rate means1 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 service1 the contracted rate 7reflected as a dollar amount7 in effect between such plan or coverage and such provider for such item or service1 regardless of whether such rate is calculated based on a set amount1 a fee schedule1 or an amount derived from another amount1 or a formula1 or other method4 4 7,b7 ,clerical amendment ,the table of contents in section #a of the ,employee ,retirement ,income ,security ,act of #aigd is amended by striking the item relating to section #gai and inserting the following new item3 ,sec4 #gai4 ,transparency in coverage4 4 7b7 ,application programming interface report ,not later than ,january #a1 #bjbe1 and annually thereafter1 the ,secretary of ,health and ,human ,services shall1 in consultation with the ,office of the ,national ,coordinator for ,health ,information ,technology1 ,department of ,labor1 the ,department of the ,treasury1 and stakeholders1 submit to the ,house ,committees on ,education and the ,workforce1 ,energy and ,commerce1 and ,ways and ,means1 and the ,senate ,committees on ,finance and ,health1 ,education1 ,labor1 and ,pensions a report on the use of standards-based application programming interfaces 7in this subsection referred to as ,a,p,is7 to facilitate access to health care price transparency information and the interoperability of other medical information4 ,such report shall include an evaluation of the capacity of the ,department of ,health and ,human ,services1 the ,department of ,labor1 and the ,department of the ,treasury to regulate and implement standards related to ,a,p,is and recommendations for improving such capacity4 ,such report shall include the following3 7#a7 ,a description of current use1 and proposed use1 of ,a,p,is under ,federal rules to facilitate interoperability1 including information related to capacity constraints within the agencies1 barriers to adoption1 privacy and security1 administrative burdens and efficiencies1 care coordination1 and levels of compliance4 7#b7 ,a description of the feasibility of agency participation in the development of ,a,p,is to enable application access to price transparency data under the amendments made by subsection 7a74 7#c7 ,a specification of the timeline for which such data standards can be required to make such data accessible via an ,,api4 7#d7 ,an analysis of the benefits and challenges of implementing standards-based ,a,p,is for price transparency data1 including the ability for consumers to access rate and payment information and the amount of cost-sharing 7including deductibles1 copayments1 and coinsurance7 under the consumer's plan through third-party internet-based tools and applications4 7#e7 ,an analysis of the impact that ,a,p,is which provide real-time access to pricing and cost-sharing information may have in increasing the amount of services shoppable for individuals1 such as by standardizing more health care spend via episode bundles4 7#f7 ,an analysis of which health care items and services may be useful under ,,api1 such as those for which prices change with the greatest frequency4 7#g7 ,an analysis of the cost of ,,api standards implementation on issuers1 employers1 and other private-sector entities4 7#h7 ,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 standards4 7#i7 ,an analysis of the interaction with ,,api standards and ,federal health information privacy standards4 7c7 ,provider tool report 7#a7 ,in general ,not later than #a year after the date of the enactment of this ,act1 ,the ,secretary of ,health and ,human ,services1 acting through the ,administrator of the ,centers for ,medicare ,medicaid ,services1 shall1 in consultation with stakeholders1 conduct a study and submit to the ,house ,committees on ,education and the ,workforce1 ,energy and ,commerce1 and ,ways and ,means1 and the ,senate ,committees on ,finance and ,health1 ,education1 ,labor1 and ,pensions a report on the usefulness and feasibility of the establishment of a provider tool by a group health plan1 or a health insurance issuer offering group and individual health insurance coverage1 in facilitating the provision of information made available pursuant to the amendments made by subsection 7a74 ,such report shall include the following3 7,a7 ,a description of the feasibility of establishing a requirement for the various types of plans and coverage to offer such a provider tool1 including any challenges to establishing a provider tool using the same technology platform as the self-service tool described in such amendments4 7,b7 ,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 consideration4 7,c7 ,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 requirement4 7,d7 ,a description of the usability and expected utilization of such tool among providers1 including among different provider types4 7,e7 ,an analysis of the impact of a provider tool in value-based care arrangements4 7,f7 ,an analysis on the potential impact of the provider tool on-- 7i7 patients' out-of-pocket spending2 7ii7 plan design1 including impacts on cost-sharing requirements2 7iii7 care coordination and quality2 7iv7 plan premiums2 7v7 overall health care spending and utilization2 and 7vi7 health care access in rural areas4 7,g7 ,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 #bgii;,b-#f 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 #bgii;,a-#a7;f7 of such ,act4 7,h7 ,an analysis of which health care items and services1 would be most useful for patients utilizing a provider tool4 7,i7 ,an analysis of rulemaking required to ensure such a tool complies with federal health information privacy standards4 7,j7 ,an analysis of the burden and cost of the creation of a provider tool by plans and coverage on providers1 issuers1 employers1 and other private-sector entities4 7,k7 ,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 standards4 7#b7 ,definition ,the term provider tool means a tool designed to facilitate the provision of information made available pursuant to the amendments made by subsection 7a7 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 request1 upon the request of the provider1 and with the consent of such individual4 7d7 ,reports 7#a7 ,compliance ,not later than ,january #a1 #bjbg1 the ,comptroller ,general of the ,united ,states shall submit to ,congress a report containing-- 7,a7 an analysis of compliance with the amendments made by this section2 7,b7 an analysis of enforcement of such amendments by the ,secretaries of ,health and ,human ,services1 ,labor1 and the ,treasury2 7,c7 recommendations relating to improving such enforcement2 and 7,d7 recommendations relating to improving public disclosure1 and public awareness1 of information required to be made available by group health plans and health insurance issuers pursuant to such amendments4 7#b7 ,prices ,not later than ,january #a1 #bjbh1 and biennially thereafter1 the ,secretaries of ,health and ,human ,services1 ,labor1 and the ,treasury shall jointly submit to ,congress a report containing an assessment of differences in negotiated prices 7and any trends in such prices7 in the private market between-- 7,a7 rural and urban areas2 7,b7 the individual1 small group1 and large group markets2 7,c7 consolidated and nonconsolidated health care provider areas 7as specified by the ,secretary of ,health and ,human ,services72 7,d7 nonprofit and for-profit hospitals2 7,e7 nonprofit and for-profit insurers2 and 7,f7 insurers serving local or regional areas and insurers serving multistate or national areas4 7e7 ,quality report ,not later than #a year after the date of enactment of this subsection1 the ,secretaries of ,health and ,human ,services1 ,labor1 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 7a74 ,such report shall include recommendations for legislative and regulatory actions to identify appropriate metrics for assessing and comparing quality of care4 7f7 ,continued applicability of rules for previous years ,nothing in the amendments made by subsection 7a7 may be construed as affecting the applicability of the rule entitled ,transparency in ,coverage published by the ,department of the ,treasury1 the ,department of ,labor1 and the ,department of ,health and ,human ,services on ,november #ab1 #bjbj 7#he ,fed4 ,reg4 #gbaeh71 for any plan year beginning before ,january #a1 #bjbf4 #ajf4 ,pharmacy benefits price transparency 7a7 ,,phsa ,title ,,xxvii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg et seq47 is amended-- 7#a7 in part ,d 7#db ,u4,s4,c4 #cjj;gg-#aaa et seq471 by adding at the end the following new section3 #bgii;,a-#aa4 ,oversight of pharmacy benefits manager services 7a7 ,in general ,for plan years beginning on or after the date that is #b years after the date of enactment of this section1 a group health plan or a health insurance issuer offering group health insurance coverage1 or an entity or subsidiary providing pharmacy benefits management services on behalf of such a plan or issuer1 shall not enter into a contract with a drug manufacturer1 distributor1 wholesaler1 subcontractor1 rebate aggregator1 or any other third party that limits 7or delays beyond the applicable reporting period described in subsection 7b77#a77 the disclosure of information to group health plans in such a manner that prevents such plan1 issuer1 or entity from making the reports described in subsection 7b74 7b7 ,reports 7#a7 ,in general ,with respect to plan years beginning on or after the date that is #b years after the date of enactment of this section1 not less frequently than every #f months 7or at the request of a group health plan1 not less frequently than quarterly1 but under the same conditions1 terms1 and cost of the semiannual report under this subsection71 a group health plan or health insurance issuer offering group health insurance coverage1 or an entity providing pharmacy benefits management services on behalf of such a plan or issuer1 shall submit to the group health plan a report in accordance with this section4 ,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 7#b74 7#b7 ,information described ,for purposes of paragraph 7#a71 the information described in this paragraph is1 with respect to drugs covered by a group health plan or health insurance issuer offering group health insurance coverage during each reporting period-- 7,a7 in the case of such a plan offered by a specified large employer 7or such coverage offered in connection with such a plan offered by a specified large employer7-- 7i7 a list of drugs for which a claim was filed and1 with respect to each such drug on such list-- 7,i7 the brand name1 chemical entity1 and ,national ,drug ,code2 7,,ii7 the type of dispensing channel used to furnish such drug1 including retail1 mail order1 or specialty pharmacy2 7,,iii7 with respect to each drug dispensed under each type of dispensing channel 7including retail1 mail order1 or specialty pharmacy7-- 7aa7 whether such drug is a brand name drug or a generic drug1 and-- 7,,aa7 in the case of a brand name drug1 the wholesale acquisition cost1 listed as cost per days supply and cost per dosage unit1 on the date such drug was dispensed2 and 7,,bb7 in the case of a generic drug1 the average wholesale price1 listed as cost per days supply and cost per dosage unit1 on the date such drug was dispensed2 and 7bb7 the total number of-- 7,,aa7 prescription claims 7including original prescriptions and refills72 7,,bb7 participants1 beneficiaries1 and enrollees for whom a claim for such drug was filed2 7,,cc7 dosage units per fill of such drug2 and 7,,dd7 days supply of such drug per fill2 7,,iv7 the net price per course of treatment or single fill1 such as a #cj-;day supply or #ij-;day supply to the plan or coverage after manufacturer rebates1 fees1 and other remuneration or adjustments2 7,v7 the total amount of out-of-pocket spending by participants1 beneficiaries1 and enrollees on such drug1 including spending through copayments1 coinsurance1 and deductibles2 7,,vi7 the total net spending by the plan or coverage during the reporting period2 7,,vii7 the total amount received1 or expected to be received1 by the plan or coverage from any entity in drug manufacturer rebates1 fees1 alternative discounts1 and all other remuneration received from an entity or any third party 7including group purchasing organizations7 other than the plan sponsor2 7,,viii7 the total amount received1 or expected to be received by the plan or issuer1 from drug manufacturers in rebates1 fees1 alternative discounts1 or other remuneration-- 7aa7 that has been paid1 or is to be paid1 by drug manufacturers for claims incurred during the reporting period2 and 7bb7 that is related to utilization rebates for such drug2 and 7,,ix7 to the extent feasible1 information on the total amount of remuneration1 including copayment assistance dollars paid1 copayment cards applied1 or other discounts provided by each drug manufacturer 7or entity administering copay assistance on behalf of such drug manufacturer7 to the participants1 beneficiaries1 and enrollees enrolled in such plan or coverage for such drug2 7ii7 for each category or class of drugs for which a claim was filed1 a breakdown of the total gross spending on drugs in such category or class before rebates1 price concessions1 alternative discounts1 or other remuneration from drug manufacturers1 and the net spending after such rebates1 price concessions1 alternative discounts1 or other remuneration from drug manufacturers1 including-- 7,i7 the number of participants1 beneficiaries1 and enrollees who filled a prescription for a drug in such category or class1 including the ,national ,drug ,code for each such drug2 7,,ii7 if applicable1 a description of the formulary tiers and utilization mechanisms 7such as prior authorization or step therapy7 employed for drugs in that category or class2 and 7,,iii7 the total out-of-pocket spending under the plan or coverage by participants1 beneficiaries1 and enrollees1 including spending through copayments1 coinsurance1 and deductibles2 7iii7 in the case of a drug for which gross spending by such plan1 coverage1 or entity exceeded #aj1jjj during the reporting period-- 7,i7 a list of all other drugs in the same therapeutic category or class2 and 7,,ii7 the rationale for the formulary placement of such drug in that therapeutic category or class1 if applicable2 and 7iv7 in the case such plan or coverage 7or an entity providing pharmacy benefits management services on behalf of such plan or coverage7 has an affiliated pharmacy or pharmacy under common ownership-- 7,i7 the percentage of total prescriptions dispensed by such pharmacies to individuals enrolled in such plan or coverage2 7,,ii7 a list of all drugs dispensed by such pharmacies to individuals enrolled in such plan or coverage1 and1 with respect to each drug dispensed-- 7aa7 the amount charged1 per dosage unit1 per #cj-;day supply1 or per #ij-;day supply 7as applicable7 to the plan or issuer1 and to participants1 beneficiaries1 and enrollees enrolled in such plan or coverage2 7bb7 the median amount charged to such plan or issuer1 and the interquartile range of the costs1 per dosage unit1 per #cj-;day supply1 and per #ij-;day supply1 including amounts paid by the participants1 beneficiaries1 and enrollees1 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 coverage2 7cc7 the lowest cost per dosage unit1 per #cj-;day supply and per #ij-;day supply1 for each such drug1 including amounts charged to the plan and participants1 beneficiaries1 and enrollees1 that is available from any pharmacy included in the network of such plan or coverage2 and 7dd7 the net acquisition cost per dosage unit1 per #cj-;day supply1 and per #ij-;day supply1 if such drug is subject to a maximum price discount2 7,b7 in the case of a plan or coverage not described in subparagraph 7,a7-- 7i7 the total net spending by the plan or coverage for all drugs covered by such plan or coverage during such reporting period2 7ii7 the total amount received1 or expected to be received1 by the plan or coverage from any entity in drug manufacturer rebates1 fees1 alternative discounts1 and all other remuneration received from an entity or any third party 7including group purchasing organizations7 other than the plan sponsor for all such drugs2 and 7iii7 to the extent feasible1 information on the total amount of remuneration1 including copayment assistance dollars paid1 copayment cards applied1 or other discounts provided by each drug manufacturer 7or entity administering copay assistance on behalf of such drug manufacturer7 to the participants1 beneficiaries1 and enrollees enrolled in such plan or coverage for such drugs2 7,c7 amounts paid directly or indirectly in rebates1 fees1 or any other type of compensation 7as defined in section #djh7;b77#b77;,b77ii77dd77,,aa7 of the ,employee ,retirement ,income ,security ,act7 to brokers1 consultants1 advisors1 or any other individual or firm1 for the referral of the group health plan's or health insurance issuer's business to an entity providing pharmacy benefits management services1 including the identity of the recipient of such amounts2 7,d7 an explanation of any benefit design parameters that encourage or require participants1 beneficiaries1 and enrollees in such plan or coverage to fill prescriptions at mail order1 specialty1 or retail pharmacies that are affiliated with or under common ownership with the entity providing pharmacy benefit management services under such plan or coverage1 including mandatory mail and specialty home delivery programs1 retail and mail auto-refill programs1 and cost-sharing assistance incentives directly or indirectly funded by such entity2 and 7,e7 total gross spending on all drugs during the reporting period4 7#c7 ,privacy requirements 7,a7 ,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 7#a7 in a manner consistent with the privacy1 security1 and breach notification regulations promulgated under section #acdjb7;a7 of the ,health ,information ,technology for ,clinical ,health ,act and consistent with the ,,hipaa privacy regulations 7as defined in section #aahj7;b77#c7 of the ,social ,security ,act7 and shall restrict the use and disclosure of such information according to such privacy1 security1 and breach notification regulations and such ,,hipaa privacy regulations4 7,b7 ,additional requirements 7i7 ,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 7#a7 shall ensure that such report contains only summary health information1 as defined in section #afd4ejd7;a7 of title #de1 ,code of ,federal ,regulations 7or successor regulations74 7ii7 ,restrictions ,a group health plan shall comply with section #afd4ejd7;f7 of title #de1 ,code of ,federal ,regulations 7or a successor regulation7 and a plan sponsor shall act in accordance with the terms of the agreement described in such section4 7,c7 ,rule of construction ,nothing in this section shall be construed to modify the requirements for the creation1 receipt1 maintenance1 or transmission of protected health information under the ,,hipaa privacy regulations 7as defined in section #aahj7;b77#c7 of the ,social ,security ,act74 7#d7 ,disclosure and redisclosure 7,a7 ,limitation to business associates ,a group health plan receiving a report under paragraph 7#a7 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 #afj4ajc of title #de1 ,code of ,federal ,regulations 7or successor regulations7 or as permitted by the ,,hipaa ,privacy ,rule 7#de ,,cfr parts #afj and #afd1 subparts ,a and ,e74 7,b7 ,clarification regarding public disclosure of information ,nothing in this section shall prevent a group health plan or health insurance issuer offering group health insurance coverage1 or an entity providing pharmacy benefits management services on behalf of such a plan or coverage1 from placing reasonable restrictions on the public disclosure of the information contained in a report described in paragraph 7#a71 except that such plan1 issuer1 or entity may not restrict disclosure of such report to the ,department of ,health and ,human ,services1 the ,department of ,labor1 the ,department of the ,treasury1 or the ,comptroller ,general of the ,united ,states4 7,c7 ,limited form of report ,the ,secretary shall define through rulemaking a limited form of the report under paragraph 7#a7 required with respect to group health plans where the plan sponsors of such plans are drug manufacturers1 drug wholesalers1 or other direct participants in the drug supply chain1 in order to prevent anti-competitive behavior4 7#e7 ,report to ,,gao ,a group health plan or health insurance issuer offering group health insurance coverage1 or an entity providing pharmacy benefits management services on behalf of such plan or coverage1 shall submit to the ,comptroller ,general of the ,united ,states each of the first #d reports submitted to a group health plan under paragraph 7#a7 and other such reports as requested1 in accordance with the privacy requirements under paragraph 7#c71 the disclosure and redisclosure standards under paragraph 7#d71 the standards specified pursuant to paragraph 7#f71 and such other information that the ,comptroller ,general determines necessary to carry out the study under section #ajf7;d7 of the ,lower ,costs1 ,more ,transparency ,act4 7#f7 ,standard format ,not later than #a year after the date of enactment of this section1 the ,secretary shall specify through rulemaking standards for group health plans1 health insurance issuers offering group health insurance coverage1 and entities providing pharmacy benefits management services on behalf of such plans or coverage1 required to submit reports under paragraph 7#a7 to submit such reports in a standard format4 7c7 ,enforcement 7#a7 ,in general ,the ,secretary shall enforce this section4 7#b7 ,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 7a7 or fails to provide the information required under subsection 7b7 shall be subject to a civil monetary penalty in the amount of #aj1jjj for each day during which such violation continues or such information is not disclosed or reported4 7#c7 ,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 #ajj1jjj for each item of false information4 ,such civil money penalty shall be in addition to other penalties as may be prescribed by law4 7#d7 ,procedure ,the provisions of section #aabh;,a of the ,social ,security ,act1 other than subsections 7a7 and 7b7 and the first sentence of subsection 7c77#a7 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 section4 7#e7 ,waivers ,the ,secretary may waive penalties under paragraph 7#b71 or extend the period of time for compliance with a requirement of this section1 for an entity in violation of this section that has made a good-faith effort to comply with the requirements in this section4 7d7 ,rule of construction ,nothing in this section shall be construed to permit a group health plan1 health insurance issuer1 or entity providing pharmacy benefits management services on behalf of such plan or coverage1 to restrict disclosure to1 or otherwise limit the access of1 the ,department of ,health and ,human ,services to a report described in subsection 7b77#a7 or information related to compliance with subsection 7a7 or 7b7 by entities subject to such subsection4 7e7 ,definitions ,in this section3 7#a7 ,specified large employer ,the term specified large employer means1 in connection with a group health plan with respect to a calendar year and a plan year1 an employer who employed an average of at least #ej employees on business days during the preceding calendar year and who employs at least #a employee on the first day of the plan year4 7#b7 ,wholesale acquisition cost ,the term wholesale acquisition cost has the meaning given such term in section #ahdg;,a7c77#f77;,b7 of the ,social ,security ,act4 2 and 7#b7 in section #bgbc 7#db ,u4,s4,c4 #cjj;gg-#bb7-- 7,a7 in subsection 7a7-- 7i7 in paragraph 7#a71 by inserting 7other than subsections 7a7 and 7b7 of section #bgii;,a-#aa7 after part ,d2 and 7ii7 in paragraph 7#b71 by inserting 7other than subsections 7a7 and 7b7 of section #bgii;,a-#aa7 after part ,d2 and 7,b7 in subsection 7b7-- 7i7 in paragraph 7#a71 by inserting 7other than subsections 7a7 and 7b7 of section #bgii;,a-#aa7 after part ,d2 7ii7 in paragraph 7#b77;,a71 by inserting 7other than subsections 7a7 and 7b7 of section #bgii;,a-#aa7 after part ,d2 and 7iii7 in paragraph 7#b77;,c77ii71 by inserting 7other than subsections 7a7 and 7b7 of section #bgii;,a-#aa7 after part ,d4 7b7 ,,erisa 7#a7 ,in general ,subtitle ,b of title ,i of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #ajba et seq47 is amended-- 7,a7 in subpart ,b of part #g 7#bi ,u4,s4,c4 #aahe et seq471 by adding at the end the following3 #gbf4 ,oversight of pharmacy benefit manager services 7a7 ,in general ,for plan years beginning on or after the date that is #b years after the date of enactment of this section1 a group health plan or a health insurance issuer offering group health insurance coverage1 or an entity or subsidiary providing pharmacy benefits management services on behalf of such a plan or issuer1 shall not enter into a contract with a drug manufacturer1 distributor1 wholesaler1 subcontractor1 rebate aggregator1 or any other third party that limits 7or delays beyond the applicable reporting period described in subsection 7b77#a77 the disclosure of information to group health plans in such a manner that prevents such plan1 issuer1 or entity from making the reports described in subsection 7b74 7b7 ,reports 7#a7 ,in general ,with respect to plan years beginning on or after the date that is #b years after the date of enactment of this section1 not less frequently than every #f months 7or at the request of a group health plan1 not less frequently than quarterly1 but under the same conditions1 terms1 and cost of the semiannual report under this subsection71 a group health plan or health insurance issuer offering group health insurance coverage1 or an entity providing pharmacy benefits management services on behalf of such a plan or issuer1 shall submit to the group health plan a report in accordance with this section4 ,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 7#b74 7#b7 ,information described ,for purposes of paragraph 7#a71 the information described in this paragraph is1 with respect to drugs covered by a group health plan or health insurance issuer offering group health insurance coverage during each reporting period-- 7,a7 in the case of such a plan offered by a specified large employer 7or such coverage offered in connection with such a plan offered by a specified large employer7-- 7i7 a list of drugs for which a claim was filed and1 with respect to each such drug on such list-- 7,i7 the brand name1 chemical entity1 and ,national ,drug ,code2 7,,ii7 the type of dispensing channel used to furnish such drug1 including retail1 mail order1 or specialty pharmacy2 7,,iii7 with respect to each drug dispensed under each type of dispensing channel 7including retail1 mail order1 or specialty pharmacy7-- 7aa7 whether such drug is a brand name drug or a generic drug1 and-- 7,,aa7 in the case of a brand name drug1 the wholesale acquisition cost1 listed as cost per days supply and cost per dosage unit1 on the date such drug was dispensed2 and 7,,bb7 in the case of a generic drug1 the average wholesale price1 listed as cost per days supply and cost per dosage unit1 on the date such drug was dispensed2 and 7bb7 the total number of-- 7,,aa7 prescription claims 7including original prescriptions and refills72 7,,bb7 participants and beneficiaries for whom a claim for such drug was filed2 7,,cc7 dosage units per fill of such drug2 and 7,,dd7 days supply of such drug per fill2 7,,iv7 the net price per course of treatment or single fill1 such as a #cj-;day supply or #ij-;day supply to the plan or coverage after manufacturer rebates1 fees1 and other remuneration or adjustments2 7,v7 the total amount of out-of-pocket spending by participants1 beneficiaries1 and enrollees on such drug1 including spending through copayments1 coinsurance1 and deductibles2 7,,vi7 the total net spending by the plan or coverage during the reporting period2 7,,vii7 the total amount received1 or expected to be received1 by the plan or coverage from any entity in drug manufacturer rebates1 fees1 alternative discounts1 and all other remuneration received from an entity or any third party 7including group purchasing organizations7 other than the plan sponsor2 7,,viii7 the total amount received1 or expected to be received by the plan or issuer1 from drug manufacturers in rebates1 fees1 alternative discounts1 or other remuneration-- 7aa7 that has been paid1 or is to be paid1 by drug manufacturers for claims incurred during the reporting period2 and 7bb7 that is related to utilization rebates for such drug2 and 7,,ix7 to the extent feasible1 information on the total amount of remuneration1 including copayment assistance dollars paid1 copayment cards applied1 or other discounts provided by each drug manufacturer 7or entity administering copay assistance on behalf of such drug manufacturer7 to the participants1 beneficiaries1 and enrollees enrolled in such plan or coverage for such drug2 7ii7 for each category or class of drugs for which a claim was filed1 a breakdown of the total gross spending on drugs in such category or class before rebates1 price concessions1 alternative discounts1 or other remuneration from drug manufacturers1 and the net spending after such rebates1 price concessions1 alternative discounts1 or other remuneration from drug manufacturers1 including-- 7,i7 the number of participants1 beneficiaries1 and enrollees who filled a prescription for a drug in such category or class1 including the ,national ,drug ,code for each such drug2 7,,ii7 if applicable1 a description of the formulary tiers and utilization mechanisms 7such as prior authorization or step therapy7 employed for drugs in that category or class2 and 7,,iii7 the total out-of-pocket spending under the plan or coverage by participants1 beneficiaries1 and enrollees1 including spending through copayments1 coinsurance1 and deductibles2 7iii7 in the case of a drug for which gross spending by such plan1 coverage1 or entity exceeded #aj1jjj during the reporting period-- 7,i7 a list of all other drugs in the same therapeutic category or class2 and 7,,ii7 the rationale for the formulary placement of such drug in that therapeutic category or class1 if applicable2 and 7iv7 in the case such plan or coverage 7or an entity providing pharmacy benefits management services on behalf of such plan or coverage7 has an affiliated pharmacy or pharmacy under common ownership-- 7,i7 the percentage of total prescriptions dispensed by such pharmacies to individuals enrolled in such plan or coverage2 7,,ii7 a list of all drugs dispensed by such pharmacies to individuals enrolled in such plan or coverage1 and1 with respect to each drug dispensed-- 7aa7 the amount charged1 per dosage unit1 per #cj-;day supply1 or per #ij-;day supply 7as applicable7 to the plan or issuer1 and to participants1 beneficiaries1 and enrollees enrolled in such plan or coverage2 7bb7 the median amount charged to such plan or issuer1 and the interquartile range of the costs1 per dosage unit1 per #cj-;day supply1 and per #ij-;day supply1 including amounts paid by the participants1 beneficiaries1 and enrollees1 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 coverage2 7cc7 the lowest cost per dosage unit1 per #cj-;day supply and per #ij-;day supply1 for each such drug1 including amounts charged to the plan and participants1 beneficiaries1 and enrollees1 that is available from any pharmacy included in the network of such plan or coverage2 and 7dd7 the net acquisition cost per dosage unit1 per #cj-;day supply1 and per #ij-;day supply1 if such drug is subject to a maximum price discount2 7,b7 in the case of a plan or coverage not described in subparagraph 7,a7-- 7i7 the total net spending by the plan or coverage for all drugs covered by such plan or coverage during such reporting period2 7ii7 the total amount received1 or expected to be received1 by the plan or coverage from any entity in drug manufacturer rebates1 fees1 alternative discounts1 and all other remuneration received from an entity or any third party 7including group purchasing organizations7 other than the plan sponsor for all such drugs2 and 7iii7 to the extent feasible1 information on the total amount of remuneration1 including copayment assistance dollars paid1 copayment cards applied1 or other discounts provided by each drug manufacturer 7or entity administering copay assistance on behalf of such drug manufacturer7 to the participants1 beneficiaries1 and enrollees enrolled in such plan or coverage for such drugs2 7,c7 amounts paid directly or indirectly in rebates1 fees1 or any other type of compensation 7as defined in section #djh7;b77#b77;,b77ii77dd77,,aa77 to brokers1 consultants1 advisors1 or any other individual or firm1 for the referral of the group health plan's or health insurance issuer's business to an entity providing pharmacy benefits management services1 including the identity of the recipient of such amounts2 7,d7 an explanation of any benefit design parameters that encourage or require participants1 beneficiaries1 and enrollees in such plan or coverage to fill prescriptions at mail order1 specialty1 or retail pharmacies that are affiliated with or under common ownership with the entity providing pharmacy benefit management services under such plan or coverage1 including mandatory mail and specialty home delivery programs1 retail and mail auto-refill programs1 and cost-sharing assistance incentives directly or indirectly funded by such entity2 and 7,e7 total gross spending on all drugs during the reporting period4 7#c7 ,privacy requirements 7,a7 ,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 7#a7 in a manner consistent with the privacy1 security1 and breach notification regulations promulgated under section #acdjb7;a7 of the ,health ,information ,technology for ,clinical ,health ,act and consistent with the ,,hipaa privacy regulations 7as defined in section #aahj7;b77#c7 of the ,social ,security ,act7 and shall restrict the use and disclosure of such information according to such privacy1 security1 and breach notification regulations and such ,,hipaa privacy regulations4 7,b7 ,additional requirements 7i7 ,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 7#a7 shall ensure that such report contains only summary health information1 as defined in section #afd4ejd7;a7 of title #de1 ,code of ,federal ,regulations 7or successor regulations74 7ii7 ,restrictions ,a group health plan shall comply with section #afd4ejd7;f7 of title #de1 ,code of ,federal ,regulations 7or a successor regulation7 and a plan sponsor shall act in accordance with the terms of the agreement described in such section4 7,c7 ,rule of construction ,nothing in this section shall be construed to modify the requirements for the creation1 receipt1 maintenance1 or transmission of protected health information under the ,,hipaa privacy regulations 7as defined in section #aahj7;b77#c7 of the ,social ,security ,act74 7#d7 ,disclosure and redisclosure 7,a7 ,limitation to business associates ,a group health plan receiving a report under paragraph 7#a7 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 #afj4ajc of title #de1 ,code of ,federal ,regulations 7or successor regulations7 or as permitted by the ,,hipaa ,privacy ,rule 7#de ,,cfr parts #afj and #afd1 subparts ,a and ,e74 7,b7 ,clarification regarding public disclosure of information ,nothing in this section shall prevent a group health plan or health insurance issuer offering group health insurance coverage1 or an entity providing pharmacy benefits management services on behalf of such a plan or coverage1 from placing reasonable restrictions on the public disclosure of the information contained in a report described in paragraph 7#a71 except that such plan1 issuer1 or entity may not restrict disclosure of such report to the ,department of ,health and ,human ,services1 the ,department of ,labor1 the ,department of the ,treasury1 or the ,comptroller ,general of the ,united ,states4 7,c7 ,limited form of report ,the ,secretary shall define through rulemaking a limited form of the report under paragraph 7#a7 required with respect to group health plans where the plan sponsors of such plans are drug manufacturers1 drug wholesalers1 or other direct participants in the drug supply chain1 in order to prevent anti-competitive behavior4 7#e7 ,report to ,,gao ,a group health plan or health insurance issuer offering group health insurance coverage1 or an entity providing pharmacy benefits management services on behalf of such plan or coverage1 shall submit to the ,comptroller ,general of the ,united ,states each of the first #d reports submitted to a group health plan under paragraph 7#a7 and other such reports as requested1 in accordance with the privacy requirements under paragraph 7#c71 the disclosure and redisclosure standards under paragraph 7#d71 the standards specified pursuant to paragraph 7#f71 and such other information that the ,comptroller ,general determines necessary to carry out the study under section #ajf7;d7 of the ,lower ,costs1 ,more ,transparency ,act4 7#f7 ,standard format ,not later than #a year after the date of enactment of this section1 the ,secretary shall specify through rulemaking standards for group health plans1 health insurance issuers offering group health insurance coverage1 and entities providing pharmacy benefits management services on behalf of such plans or coverage1 required to submit reports under paragraph 7#a7 to submit such reports in a standard format4 7c7 ,rule of construction ,nothing in this section shall be construed to permit a group health plan1 health insurance issuer1 or entity providing pharmacy benefits management services on behalf of such plan or coverage1 to restrict disclosure to1 or otherwise limit the access of1 the ,secretary of ,labor to a report described in subsection 7b77#a7 or information related to compliance with subsection 7a7 or 7b7 by entities subject to such subsection4 7d7 ,definitions ,in this section3 7#a7 ,specified large employer ,the term specified large employer means1 in connection with a group health plan with respect to a calendar year and a plan year1 an employer who employed an average of at least #ej employees on business days during the preceding calendar year and who employs at least #a employee on the first day of the plan year4 7#b7 ,wholesale acquisition cost ,the term wholesale acquisition cost has the meaning given such term in section #ahdg;,a7c77#f77;,b7 of the ,social ,security ,act4 4 7,b7 in section #ejb 7#bi ,u4,s4,c4 #aacb7-- 7i7 in subsection 7b77#c71 by striking under subsection 7c77#i77 and inserting under paragraphs 7#i7 and 7#ac7 of subsection 7c772 and 7ii7 in subsection 7c71 by adding at the end the following new paragraph3 7#ac7 ,secretarial enforcement authority relating to oversight of pharmacy benefits manager services 7,a7 ,failure to provide information ,the ,secretary may impose a penalty against any health insurance issuer or entity providing pharmacy benefits management services that violates section #gbf7;a7 or fails to provide information required under section #gbf7;b7 in the amount of #aj1jjj for each day during which such violation continues or such information is not disclosed or reported4 7,b7 ,false information ,the ,secretary may impose a penalty against a health insurance issuer or entity providing pharmacy benefits management services that knowingly provides false information under section #gbf in an amount not to exceed #ajj1jjj for each item of false information4 ,such penalty shall be in addition to other penalties as may be prescribed by law4 7,c7 ,waivers ,the ,secretary may waive penalties under subparagraph 7,a71 or extend the period of time for compliance with a requirement of section #gbf1 for an entity in violation of such section that has made a good-faith effort to comply with such section4 4 7#b7 ,clerical amendment ,the table of contents in section #a of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #ajja et seq47 is amended by inserting after the item relating to section #gbe the following new item3 ,sec4 #gbf4 ,oversight of pharmacy benefits manager services4 4 7c7 ,,irc 7#a7 ,in general ,subchapter ,b of chapter #ajj of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following3 #ihbf4 ,oversight of pharmacy benefit manager services 7a7 ,in general ,for plan years beginning on or after the date that is #b years after the date of enactment of this section1 a group health plan1 or an entity or subsidiary providing pharmacy benefits management services on behalf of such a plan1 shall not enter into a contract with a drug manufacturer1 distributor1 wholesaler1 subcontractor1 rebate aggregator1 or any other third party that limits 7or delays beyond the applicable reporting period described in subsection 7b77#a77 the disclosure of information to group health plans in such a manner that prevents such plan or entity from making the reports described in subsection 7b74 7b7 ,reports 7#a7 ,in general ,with respect to plan years beginning on or after the date that is #b years after the date of enactment of this section1 not less frequently than every #f months 7or at the request of a group health plan1 not less frequently than quarterly1 but under the same conditions1 terms1 and cost of the semiannual report under this subsection71 a group health plan1 or an entity providing pharmacy benefits management services on behalf of such a plan1 shall submit to the group health plan a report in accordance with this section4 ,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 7#b74 7#b7 ,information described ,for purposes of paragraph 7#a71 the information described in this paragraph is1 with respect to drugs covered by a group health plan during each reporting period-- 7,a7 in the case of such a plan offered by a specified large employer-- 7i7 a list of drugs for which a claim was filed and1 with respect to each such drug on such list-- 7,i7 the brand name1 chemical entity1 and ,national ,drug ,code2 7,,ii7 the type of dispensing channel used to furnish such drug1 including retail1 mail order1 or specialty pharmacy2 7,,iii7 with respect to each drug dispensed under each type of dispensing channel 7including retail1 mail order1 or specialty pharmacy7-- 7aa7 whether such drug is a brand name drug or a generic drug1 and-- 7,,aa7 in the case of a brand name drug1 the wholesale acquisition cost1 listed as cost per days supply and cost per dosage unit1 on the date such drug was dispensed2 and 7,,bb7 in the case of a generic drug1 the average wholesale price1 listed as cost per days supply and cost per dosage unit1 on the date such drug was dispensed2 and 7bb7 the total number of-- 7,,aa7 prescription claims 7including original prescriptions and refills72 7,,bb7 participants1 beneficiaries1 and enrollees for whom a claim for such drug was filed2 7,,cc7 dosage units per fill of such drug2 and 7,,dd7 days supply of such drug per fill2 7,,iv7 the net price per course of treatment or single fill1 such as a #cj-;day supply or #ij-;day supply to the plan after manufacturer rebates1 fees1 and other remuneration or adjustments2 7,v7 the total amount of out-of-pocket spending by participants1 beneficiaries1 and enrollees on such drug1 including spending through copayments1 coinsurance1 and deductibles2 7,,vi7 the total net spending by the plan during the reporting period2 7,,vii7 the total amount received1 or expected to be received1 by the plan from any entity in drug manufacturer rebates1 fees1 alternative discounts1 and all other remuneration received from an entity or any third party 7including group purchasing organizations7 other than the plan sponsor2 7,,viii7 the total amount received1 or expected to be received by the plan1 from drug manufacturers in rebates1 fees1 alternative discounts1 or other remuneration-- 7aa7 that has been paid1 or is to be paid1 by drug manufacturers for claims incurred during the reporting period2 and 7bb7 that is related to utilization rebates for such drug2 and 7,,ix7 to the extent feasible1 information on the total amount of remuneration1 including copayment assistance dollars paid1 copayment cards applied1 or other discounts provided by each drug manufacturer 7or entity administering copay assistance on behalf of such drug manufacturer7 to the participants1 beneficiaries1 and enrollees enrolled in such plan for such drug2 7ii7 for each category or class of drugs for which a claim was filed1 a breakdown of the total gross spending on drugs in such category or class before rebates1 price concessions1 alternative discounts1 or other remuneration from drug manufacturers1 and the net spending after such rebates1 price concessions1 alternative discounts1 or other remuneration from drug manufacturers1 including-- 7,i7 the number of participants1 beneficiaries1 and enrollees who filled a prescription for a drug in such category or class1 including the ,national ,drug ,code for each such drug2 7,,ii7 if applicable1 a description of the formulary tiers and utilization mechanisms 7such as prior authorization or step therapy7 employed for drugs in that category or class2 7,,iii7 the total out-of-pocket spending under the plan by participants1 beneficiaries1 and enrollees1 including spending through copayments1 coinsurance1 and deductibles2 and 7iii7 in the case of a drug for which gross spending by such plan or entity exceeded #aj1jjj during the reporting period-- 7,i7 a list of all other drugs in the same therapeutic category or class2 and 7,,ii7 the rationale for the formulary placement of such drug in that therapeutic category or class1 if applicable2 and 7iv7 in the case such plan 7or an entity providing pharmacy benefits management services on behalf of such plan7 that has an affiliated pharmacy or pharmacy under common ownership-- 7,i7 the percentage of total prescriptions dispensed by such pharmacies to individuals enrolled in such plan2 7,,ii7 a list of all drugs dispensed by such pharmacies to individuals enrolled in such plan1 and1 with respect to each drug dispensed-- 7aa7 the amount charged1 per dosage unit1 per #cj-;day supply1 or per #ij-;day supply 7as applicable7 to the plan1 and to participants1 beneficiaries1 and enrollees enrolled in such plan2 7bb7 the median amount charged to such plan1 and the interquartile range of the costs1 per dosage unit1 per #cj-;day supply1 and per #ij-;day supply1 including amounts paid by the participants1 beneficiaries1 and enrollees1 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 plan2 7cc7 the lowest cost per dosage unit1 per #cj-;day supply and per #ij-;day supply1 for each such drug1 including amounts charged to the plan and participants1 beneficiaries1 and enrollees1 that is available from any pharmacy included in the network of such plan2 and 7dd7 the net acquisition cost per dosage unit1 per #cj-;day supply1 and per #ij-;day supply1 if such drug is subject to a maximum price discount2 7,b7 in the case of a plan not described in subparagraph 7,a7-- 7i7 the total net spending by the plan for all drugs covered by such plan during such reporting period2 7ii7 the total amount received1 or expected to be received1 by the plan from any entity in drug manufacturer rebates1 fees1 alternative discounts1 and all other remuneration received from an entity or any third party 7including group purchasing organizations7 other than the plan sponsor for all such drugs2 and 7iii7 to the extent feasible1 information on the total amount of remuneration1 including copayment assistance dollars paid1 copayment cards applied1 or other discounts provided by each drug manufacturer 7or entity administering copay assistance on behalf of such drug manufacturer7 to the participants1 beneficiaries1 and enrollees enrolled in such plan for such drugs2 7,c7 amounts paid directly or indirectly in rebates1 fees1 or any other type of compensation 7as defined in section #djh7;b77#b77;,b77ii77dd77,,aa7 of the ,employee ,retirement ,income ,security ,act7 to brokers1 consultants1 advisors1 or any other individual or firm1 for the referral of the group health plan's business to an entity providing pharmacy benefits management services1 including the identity of the recipient of such amounts2 7,d7 an explanation of any benefit design parameters that encourage or require participants1 beneficiaries1 and enrollees in such plan to fill prescriptions at mail order1 specialty1 or retail pharmacies that are affiliated with or under common ownership with the entity providing pharmacy benefit management services under such plan1 including mandatory mail and specialty home delivery programs1 retail and mail auto-refill programs1 and cost-sharing assistance incentives directly or indirectly funded by such entity2 and 7,e7 total gross spending on all drugs during the reporting period4 7#c7 ,privacy requirements 7,a7 ,in general ,entities providing pharmacy benefits management services on behalf of a group health plan shall provide information under paragraph 7#a7 in a manner consistent with the privacy1 security1 and breach notification regulations promulgated under section #acdjb7;a7 of the ,health ,information ,technology for ,clinical ,health ,act and consistent with the ,,hipaa privacy regulations 7as defined in section #aahj7;b77#c7 of the ,social ,security ,act7 and shall restrict the use and disclosure of such information according to such privacy1 security1 and breach notification regulations and such ,,hipaa privacy regulations4 7,b7 ,additional requirements 7i7 ,in general ,an entity providing pharmacy benefits management services on behalf of a group health plan that submits a report under paragraph 7#a7 shall ensure that such report contains only summary health information1 as defined in section #afd4ejd7;a7 of title #de1 ,code of ,federal ,regulations 7or successor regulations74 7ii7 ,restrictions ,a group health plan shall comply with section #afd4ejd7;f7 of title #de1 ,code of ,federal ,regulations 7or a successor regulation7 and a plan sponsor shall act in accordance with the terms of the agreement described in such section4 7,c7 ,rule of construction ,nothing in this section shall be construed to modify the requirements for the creation1 receipt1 maintenance1 or transmission of protected health information under the ,,hipaa privacy regulations 7as defined in section #aahj7;b77#c7 of the ,social ,security ,act74 7#d7 ,disclosure and redisclosure 7,a7 ,limitation to business associates ,a group health plan receiving a report under paragraph 7#a7 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 #afj4ajc of title #de1 ,code of ,federal ,regulations 7or successor regulations7 or as permitted by the ,,hipaa ,privacy ,rule 7#de ,,cfr parts #afj and #afd1 subparts ,a and ,e74 7,b7 ,clarification regarding public disclosure of information ,nothing in this section shall prevent a group health plan or health insurance issuer offering group health insurance coverage1 or an entity providing pharmacy benefits management services on behalf of such a plan or coverage1 from placing reasonable restrictions on the public disclosure of the information contained in a report described in paragraph 7#a71 except that such plan1 issuer1 or entity may not restrict disclosure of such report to the ,department of ,health and ,human ,services1 the ,department of ,labor1 the ,department of the ,treasury1 or the ,comptroller ,general of the ,united ,states4 7,c7 ,limited form of report ,the ,secretary shall define through rulemaking a limited form of the report under paragraph 7#a7 required with respect to group health plans where the plan sponsors of such plans are drug manufacturers1 drug wholesalers1 or other direct participants in the drug supply chain1 in order to prevent anti-competitive behavior4 7#e7 ,report to ,,gao ,a group health plan1 or an entity providing pharmacy benefits management services on behalf of such plan1 shall submit to the ,comptroller ,general of the ,united ,states each of the first #d reports submitted to a group health plan under paragraph 7#a7 and other such reports as requested1 in accordance with the privacy requirements under paragraph 7#c71 the disclosure and redisclosure standards under paragraph 7#d71 the standards specified pursuant to paragraph 7#f71 and such other information that the ,comptroller ,general determines necessary to carry out the study under section #ajf7;d7 of the ,lower ,costs1 ,more ,transparency ,act4 7#f7 ,standard format ,not later than #a year after the date of enactment of this section1 the ,secretary shall specify through rulemaking standards for group health plans1 and entities providing pharmacy benefits management services on behalf of such plans1 required to submit reports under paragraph 7#a7 to submit such reports in a standard format4 7c7 ,rule of construction ,nothing in this section shall be construed to permit a group health plan or entity providing pharmacy benefits management services on behalf of such plan1 to restrict disclosure to1 or otherwise limit the access of1 the ,secretary of ,health and ,human ,services to a report described in subsection 7b77#a7 or information related to compliance with subsections 7a7 or 7b7 by entities subject to such subsection4 7d7 ,definitions ,in this section3 7#a7 ,specified large employer ,the term specified large employer means1 in connection with a group health plan with respect to a calendar year and a plan year1 an employer who employed an average of at least #ej employees on business days during the preceding calendar year and who employs at least #a employee on the first day of the plan year4 7#b7 ,wholesale acquisition cost ,the term wholesale acquisition cost has the meaning given such term in section #ahdg;,a7c77#f77;,b7 of the ,social ,security ,act4 4 7#b7 ,clerical amendment ,the table of sections for subchapter ,b of chapter #ajj of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new item3 ,sec4 #ihbf4 ,oversight of pharmacy benefits manager services4 4 7d7 ,,gao reports 7#a7 ,report on pharmacy network design 7,a7 ,in general ,not later than #c years after the date of enactment of this ,act1 the ,comptroller ,general of the ,united ,states shall submit to ,congress a report on-- 7i7 pharmacy networks that have contracted with group health plans1 health insurance issuers offering group health insurance coverage1 or entities providing pharmacy benefits management services on behalf of such plans or issuers1 including networks with pharmacies that are under common ownership 7in whole or part7 with such plans1 issuers1 or entities 7including entities that provide pharmacy benefits administrative services on behalf of such plans or issuers72 7ii7 pharmacy network design parameters that encourage individuals enrolled in such plans or coverage to fill prescriptions at mail order1 specialty1 or retail pharmacies that are wholly or partially owned by a plan1 issuer1 or entity2 7iii7 whether such plans and issuers have options to elect different network pricing arrangements in the marketplace with entities that provide pharmacy benefits management services and the prevalence of electing such different network pricing arrangements2 7iv7 with respect to pharmacy networks that include pharmacies under common ownership described in clause 7i7-- 7,i7 whether such networks are designed to encourage individuals enrolled in a group health plan or health insurance coverage to use such pharmacies over other network pharmacies for specific services or drugs1 and if so1 the reasons the networks give for encouraging use of such pharmacies2 and 7,,ii7 whether such pharmacies are used by enrollees disproportionately more in the aggregate or for specific services or drugs compared to other network pharmacies2 7v7 the degree to which mail order1 specialty1 or retail pharmacies that dispense prescription drugs to an enrollee in a plan or coverage that are under common ownership 7in whole or part7 with plans1 issuers1 or entities providing pharmacy benefits management services or pharmacy benefits administrative services on behalf of such plan or coverage receive reimbursement that is greater than the median price charged to the plan or issuer when the same drug is dispensed to enrollees in the plan or coverage by other pharmacies included in the pharmacy network of that plan1 issuer1 or entity that are not wholly or partially owned by the plan or issuer1 or entity providing pharmacy benefits management services on behalf of such plan or issuer4 7,b7 ,requirement ,the ,comptroller ,general of the ,united ,states shall ensure that the report under subparagraph 7,a7 does not contain information that would identify a specific group health plan or health insurance issuer 7or an entity providing pharmacy benefits management services on behalf of such plan or issuer71 or otherwise contain commercial or financial information that is privileged or confidential4 7,c7 ,definitions ,in this paragraph1 the terms group health plan1 health insurance coverage1 and health insurance issuer have the meanings given such terms in section #bgia of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ia74 7#b7 ,report on copay assistance programs ,not later than #ah months after the date of the enactment of this ,act1 the ,comptroller ,general of the ,united ,states shall submit to ,congress a report on what is known about the role of copay assistance programs and the impact of such programs on commercial health insurance1 stop loss1 and drug prices4 ,such report shall include to the extent feasible-- 7,a7 a description of copay assistance programs1 including-- 7i7 the types of programs available and the methods of providing copay assistance through such programs1 including cash discounts1 copay cards1 or drugs provided to an individual at no cost2 7ii7 how such programs are funded2 7iii7 the types of entities that own1 operate1 or otherwise conduct such programs1 the types of information such entities collect1 and the direct and indirect contractual relationships between the entities in the drug supply chain that interact with such programs1 such as a drug manufacturer1 pharmacy1 wholesaler1 switch1 rebate aggregator1 pharmacy benefit manager1 and other entities in the drug supply chain2 7iv7 the effect of such programs on patient out-of-pocket spending1 including for stop-loss insurance1 and drug utilization1 including drug adherence2 and 7v7 patient eligibility criteria for such programs2 and 7,b7 an analysis of-- 7i7 the sources of funding for such programs2 and 7ii7 the effects of such programs on ,federal health care programs and the individuals enrolled in such ,federal health care programs4 #ajg4 ,reports on health care transparency tools and data 7a7 ,initial report ,not later than ,december #ca1 #bjbd1 the ,comptroller ,general of the ,united ,states shall submit to the ,committees 7as defined in subsection 7d77 an initial report that-- 7#a7 identifies and describes health care transparency tools and ,federal health care reporting requirements 7as described in subsection 7d77 that are in effect as of the date of the submission of such initial report1 including the frequency of reports with respect to each such requirement and whether any such requirements are duplicative2 7#b7 reviews how such reporting requirements are enforced2 7#c7 analyzes whether the public availability of health care transparency tools1 and the publication of data pursuant to such reporting requirements1 has-- 7,a7 been utilized and valued by consumers1 including reasons for such utilization 7or lack thereof72 and 7,b7 assisted health insurance plan sponsors and fiduciaries improve benefits1 lower health care costs for plan participants1 and meet fiduciary requirements2 7#d7 includes recommendations to the ,committees1 the ,secretary of ,health and ,human ,services1 the ,secretary of ,labor1 and the ,secretary of the ,treasury to-- 7,a7 improve the efficiency1 accuracy1 and usability of health care transparency tools2 7,b7 streamline ,federal health care reporting requirements to eliminate duplicative requirements and reduce the burden on entities required to submit reports pursuant to such provisions2 7,c7 improve the accuracy and efficiency of such reports while maintaining the integrity and usability of the data provided by such reports2 7,d7 address any gaps in data provided by such reports2 and 7,e7 ensure that the data and information reported is comparable and usable to consumers1 including patients1 plan sponsors1 and policy makers4 7b7 ,final report ,not later than ,december #ca1 #bjbh1 the ,comptroller ,general of the ,united ,states shall submit to the ,committees a report that includes-- 7#a7 the information provided in the initial report1 along with any updates to such information2 and 7#b7 any new information with respect to health care transparency tools that have been released following the submission of such initial report1 or new reporting requirements in effect as of the date of the submission of the final report4 7c7 ,report on expanding price transparency requirements ,not later than ,december #ca1 #bjbe1 the ,comptroller ,general of the ,united ,states1 in consultation with the ,secretary of ,health and ,human ,services1 health care provider groups1 and patient advocacy groups1 shall submit to the ,committees a report that includes recommendations to expand price transparency reporting requirements to additional care settings1 with an emphasis on settings where shoppable services 7as defined in subsection 7d77 are furnished4 7d7 ,definitions ,in this section3 7#a7 ,committees ,the term ,committees means the ,committee on ,ways and ,means1 the ,committee on ,energy and ,commerce1 and the ,committee on ,education and the ,workforce of the ,house of ,representatives1 and the ,committee on ,finance and the ,committee on ,health1 ,education1 ,labor1 and ,pensions of the ,senate4 7#b7 ,federal health care reporting requirements ,the term ,federal health care reporting requirements includes regulatory and statutory requirements with respect to the reporting and publication of health care price1 cost access1 and quality data1 including requirements established by the ,consolidated ,appropriations ,act of #bjba 7,public ,law #aaf-bfj71 this ,act1 and other reporting and publication requirements with respect to transparency in health care as identified by the ,comptroller ,general of the ,united ,states4 7#c7 ,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 service4 #ajh4 ,report on integration in ,medicare 7a7 ,required ,,ma and ,,pdp reporting 7#a7 ,,ma plans ,section #aheg7;e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;e77 is amended by adding at the end the following new paragraph3 7#f7 ,required disclosure of certain information relating to health care provider ownership 7,a7 ,in general ,for plan year #bjbe and for every third plan year thereafter1 each applicable ,,ma organization offering an ,,ma plan under this part during such plan year shall submit to the ,secretary1 at a time and in a manner specified by the ,secretary-- 7i7 the taxpayer identification number for each health care provider that was a specified health care provider with respect to such organization during such year2 7ii7 the total amount of incentive-based payments made to1 and the total amount of shared losses recoupments collected from1 such specified health care providers during such plan year2 and 7iii7 the total amount of incentive-based payments made to1 and the total amount of shared losses recoupments collected from1 providers of services and suppliers not described in clause 7ii7 during such plan year4 7,b7 ,definitions ,for purposes of this paragraph3 7i7 ,applicable ,,ma organization ,the term applicable ,,ma organization means1 with respect to a plan year1 an ,,ma organization with at least #be1jjj individuals enrolled under ,medicare ,advantage plans offered by such organization during such plan year4 7ii7 ,specified health care provider ,the term specified health care provider means1 with respect to an applicable ,,ma organization and a plan year1 a provider of services or supplier with respect to which such organization 7or any person with an ownership or control interest 7as defined in section #aabd7;a77#c77 in such organization7 is a person with an ownership or control interest 7as so defined74 4 7#b7 ,prescription drug plans ,section #ahfj;,d-#ab7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aab7;b77 is amended by adding at the end the following new paragraph3 7#i7 ,provision of information relating to pharmacy ownership 7,a7 ,in general ,for plan year #bjbe and for every third plan year thereafter1 each ,,pdp sponsor offering a prescription drug plan under this part during such plan year shall submit to the ,secretary1 at a time and in a manner specified by the ,secretary1 the taxpayer identification number and ,national ,provider ,identifier for each pharmacy that was a specified pharmacy with respect to such sponsor during such year4 7,b7 ,definition ,for purposes of this paragraph1 the term specified pharmacy means1 with respect to an ,,pdp sponsor offering a prescription drug plan and a plan year1 a pharmacy with respect to which-- 7i7 such sponsor 7or any person with an ownership or control interest 7as defined in section #aabd7;a77#c77 in such sponsor7 is a person with an ownership or control interest 7as so defined72 or 7ii7 a pharmacy benefit manager offering services under such plan 7or any person with an ownership or control interest 7as so defined7 in such sponsor7 is a person with an ownership or control interest 7as so defined74 4 7b7 ,med,p,a,c reports ,part ,e of title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex et seq471 as amended by section #aja1 is further amended by adding at the end the following new section3 #ahii;,d4 ,reports on vertical integration under ,medicare 7a7 ,in general ,not later than ,june #ae1 #bjbi1 and every #c years thereafter1 the ,medicare ,payment ,advisory ,commission shall submit to ,congress a report on the state of vertical integration in the health care sector during the applicable year with respect to entities participating in the ,medicare program1 including health care providers1 pharmacies1 prescription drug plan sponsors1 ,medicare ,advantage organizations1 and pharmacy benefit managers4 ,such report shall include-- 7#a7 with respect to ,medicare ,advantage organizations1 the evaluation described in subsection 7b72 7#b7 with respect to prescription drug plans1 pharmacy benefit managers1 and pharmacies1 the comparisons and evaluations described in subsection 7c72 7#c7 with respect to ,medicare ,advantage plans under which benefits are available for physician-administered drugs1 the information described in subsection 7d72 7#d7 the identifications described in subsection 7e72 and 7#e7 an analysis of the impact of such integration on health care access1 price1 quality1 and outcomes4 7b7 ,medicare ,advantage organizations ,for purposes of subsection 7a77#a71 the evaluation described in this subsection is1 with respect to ,medicare ,advantage organizations and an applicable year1 an evaluation1 taking into account patient acuity and the types of areas serviced by such organization1 of-- 7#a7 the average number of qualifying diagnoses made during such year with respect to enrollees of a ,medicare ,advantage plan offered by such organization who1 during such year1 received a health risk assessment from a specified health care provider2 7#b7 the average risk score for such enrollees who received such an assessment during such year2 7#c7 any relationship between such risk scores for such enrollees receiving such an assessment from such a provider during such year and incentive payments made to such providers2 7#d7 the average risk score for enrollees of such plan who received any item or service from a specified health care provider during such year2 7#e7 any relationship between the risk scores of enrollees under such plan and whether the enrollees have received any item or service from a specified provider2 and 7#f7 any relationship between the risk scores of enrollees under such plan that have received any item or service from a specified provider and incentive payments made under the plan to specified providers4 7c7 ,prescription drug plans ,for purposes of subsection 7a77#b71 the comparisons and evaluations described in this subsection are1 with respect to prescription drug plans and an applicable year1 the following3 7#a7 ,for each covered part ,d drug for which benefits are available under such a plan1 a comparison of the average negotiated rate in effect with specified pharmacies with such rates in effect for in-network pharmacies that are not specified pharmacies4 7#b7 ,comparisons of the following3 7,a7 ,the total amount paid by pharmacy benefit managers to specified pharmacies for covered part ,d drugs and the total amount so paid to pharmacies that are not specified pharmacies for such drugs4 7,b7 ,the total amount paid by such sponsors to specified pharmacy benefit managers as reimbursement for covered part ,d drugs and the total amount so paid to pharmacy benefit managers that are not specified pharmacy benefit managers as such reimbursement4 7,c7 ,fees paid under by plan to specified pharmacy benefit managers compared to such fees paid to pharmacy benefit managers that are not specified pharmacy benefit managers4 7#c7 ,an evaluation of the total amount of direct and indirect remuneration for covered part ,d drugs passed through to prescription drug plan sponsors and the total amount retained by pharmacy benefit managers 7including entities under contract with such a manager74 7#d7 ,to the extent that the available data permits1 an evaluation of fees charged by rebate aggregators that are affiliated with plan sponsors4 7d7 ,physician-administered drugs ,for purposes of subsection 7a77#c71 the information described in this subsection is1 with respect to physician-administered drugs for which benefits are available under a ,medicare ,advantage plan during an applicable year1 the following3 7#a7 ,with respect to each such plan1 an identification of each drug for which benefits were available under such plan only when administered by a health care provider that acquired such drug from an affiliated pharmacy4 7#b7 ,an evaluation of the difference between the total number of drugs administered by a health care provider that were acquired from affiliated pharmacies compared to the number of such drugs so administered that were acquired from pharmacies other than affiliated pharmacies1 and an evaluation of the difference in payments for such drugs so administered when acquired from a specified pharmacy and when acquired from a pharmacy that is not a specified pharmacy4 7#c7 ,an evaluation of the dollar value of all such drugs that were not so administered because of a delay attributable to an affiliated pharmacy compared to the dollar value of all such drugs that were not so administered because of a delay attributable to pharmacy that is not an affiliated pharmacy4 7#d7 ,the number of enrollees administered such a drug that was acquired from an affiliated pharmacy4 7#e7 ,the number of enrollees furnished such a drug that was acquired from a pharmacy that is not an affiliated pharmacy4 7e7 ,identifications ,for purposes of subsection 7a77#d71 the identifications described in this subsection are1 with respect to an applicable year1 identifications of each health care entity participating under the ,medicare program with respect to which another health care entity so participating is a person with an ownership or control interest 7as defined in section #aabd7;a77#c774 7f7 ,definitions ,in this section3 7#a7 ,affiliated pharmacy ,the term affiliated pharmacy means1 with respect to a ,medicare ,advantage plan offered by a ,medicare ,advantage organization1 a pharmacy with respect to which such organization 7or any person with an ownership or control interest 7as defined in section #aabd7;a77#c77 in such organization7 is a person with an ownership or control interest 7as so defined74 7#b7 ,applicable year ,the term applicable year means1 with respect to a report submitted under subsection 7a71 the first calendar year beginning at least #d years prior to the date of the submission of such report4 7#c7 ,covered part ,d drug ,the term covered part ,d drug has the meaning given such term in section #ahfj;,d-#b7;e74 7#d7 ,direct and indirect remuneration ,the term direct and indirect remuneration has the meaning given such term in section #dbc4cjh of title #db1 ,code of ,federal ,regulations 7or any successor regulation74 7#e7 ,qualifying diagnosis ,the term qualifying diagnosis means1 with respect to an enrollee of a ,medicare ,advantage plan1 a diagnosis that is taken into account in calculating a risk score for such enrollee under the risk adjustment methodology established by the ,secretary pursuant to section #ahec7;a77#c74 7#f7 ,risk score ,the term risk score means1 with respect to an enrollee of a ,medicare ,advantage plan1 the score calculated for such individual using the methodology described in paragraph 7#e74 7#g7 ,physician-administered drug ,the term physician-administered drug means a drug furnished to an individual that1 had such individual been enrolled under part ,b and not enrolled under part ,c1 would have been payable under section #ahdb7o74 7#h7 ,specified health care provider ,the term specified health care provider means1 with respect to a ,medicare ,advantage plan offered by a ,medicare ,advantage organization1 a health care provider with respect to which such organization 7or any person with an ownership or control interest 7as defined in section #aabd7;a77#c77 in such organization7 is a person with an ownership or control interest 7as so defined74 7#i7 ,specified pharmacy ,the term specified pharmacy means1 with respect to a prescription drug plan offered by a prescription drug plan sponsor1 a pharmacy with respect to which-- 7,a7 such sponsor 7or any person with an ownership or control interest 7as defined in section #aabd7;a77#c77 in such sponsor7 is a person with an ownership or control interest 7as so defined72 or 7,b7 a pharmacy benefit manager offering services under such plan 7or any person with an ownership or control interest 7as so defined7 in such sponsor7 is a person with an ownership or control interest 7as so defined74 7#aj7 ,specified pharmacy benefit manager ,the term specified pharmacy benefit manager means1 with respect to a prescription drug plan offered by a prescription drug plan sponsor1 a pharmacy benefit manager with respect to which such sponsor 7or any person with an ownership or control interest 7as defined in section #aabd7;a77#c77 in such sponsor7 is a person with an ownership or control interest 7as so defined74 4 #aji4 ,advisory ,committee 7a7 ,in general ,not later than ,january #a1 #bjbe1 the ,secretary of ,labor1 the ,secretary of ,health and ,human ,services1 and the ,secretary of the ,treasury shall jointly convene an advisory committee 7in this section referred to as the committee7 consisting of #i members to advise the ,secretaries on how to improve the usefulness1 accessibility1 and usability of information made available in accordance the amendments made by sections #aje and #ajf1 and by section #bjd of division ,,bb of the ,consolidated ,appropriation ,act1 #bjba 7,public ,law #aaf-bfj71 streamline the reporting of such information1 and ensure that-- 7#a7 such information is accurate1 accessible1 and is delivered in a form and manner consistent with the requirements of such section2 7#b7 the form and manner in which such information is delivered is routinely updated in accordance with widely-used practices in order to ensure accessibility2 and 7#c7 such information is available for audit 7including by making recommendations relating to how ,federal and ,state actors may conduct such audits74 7b7 ,membership ,the ,secretaries shall jointly appoint members representing end-users of the information described in subsection 7a74 ,vacancies on the committee shall be filled by appointment consistent with this subsection not later than #c months after the vacancy arises4 7c7 ,termination ,the committee shall terminate on ,january #a1 #bjbh4 7d7 ,nonapplicaiton of ,,faca ,the ,federal ,advisory ,committee ,act 7#e ,u4,s4,c4 ,app47 shall not apply to the committee4 #aaj4 ,report on impact of ,medicare regulations on provider and payer consolidation 7a7 ,annual report on the impact of certain ,medicare regulations on provider and payer consolidation2 public comment on provider and payer consolidation for certain proposed rules 7#a7 ,annual report ,not later than ,december #cj1 #bjbf1 and annually thereafter1 the ,secretary of ,health and ,human ,services 7in this section referred to as the ,secretary7 shall submit to ,congress a report on the impact in the aggregate on provider and payer consolidation with respect to regulations for parts ,a1 ,b1 ,c1 and ,d of title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq47 implemented in the calendar year immediately prior to such report4 ,such report shall include regulations that-- 7,a7 implement a change to an applicable payment system1 a rate schedule1 or another payment system under part ,a1 ,b1 ,c1 or ,d of such title2 or 7,b7 result in a significant rule effecting provider or payer consolidation4 7#b7 ,public comment on impact to provider and payer consolidation ,beginning for #bjbe1 as part of any notice and comment rulemaking process that will result in a significant rule effecting provider or payer consolidation with respect to a proposed rule for parts ,a1 ,b1 ,c1 and ,d of title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;j et seq471 the ,secretary shall seek public comment on the projected impact of such proposed rule on provider and payer consolidation in the aggregate4 7#c7 ,definitions ,in this section3 7,a7 ,provider and payer consolidation ,the term provider and payer consolidation includes the vertical or horizontal integration among providers of services 7as defined in subsection 7u7 of section #ahfa of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex771 suppliers 7as defined in subsection 7d7 of such section71 accountable care organizations under section #ahii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;jjj71 ,medicare ,advantage organizations1 ,,pdp sponsors1 pharmacy benefit managers1 pharmacies1 and integrated delivery systems4 7,b7 ,applicable payment system ,the term applicable payment system includes-- 7i7 with respect to outpatient hospital services1 the prospective payment system for covered ,,opd services established under section #ahcc7t7 of such ,act 7#db ,u4,s4,c4 #acie7l772 and 7ii7 with respect to physicians' services1 the physician fee schedules established under section #ahdh of such ,act 7#db ,u4,s4,c4 #aciew-#d74 7b7 ,consideration of effects on provider and payer consolidation with respect to ,,cmi models 7#a7 ,in general ,section #aaae;,a7b77#d77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7b77#d77;,a77 is amended-- 7,a7 in clause 7i71 by striking at the end and2 7,b7 in clause 7ii71 by striking the period at the end and inserting 2 and2 and 7,c7 by adding at the end the following new clause3 7iii7 the extent to which1 and how1 the model has effected and could effect provider and payer consolidation1 which includes the vertical or horizontal integration among providers of services 7as defined in subsection 7u7 of section #ahfa71 suppliers 7as defined in subsection 7d7 of such section71 and accountable care organizations under section #ahii4 4 7#b7 ,effective date ,the amendments made by paragraph 7#a7 shall apply with respect to models tested on or after ,january #a1 #bjbe4 #aaa4 ,implementation funding 7a7 ,in general ,for the purposes described in subsection 7b71 there are appropriated1 in addition to amounts otherwise available1 out of amounts in the ,treasury not otherwise appropriated1 to the ,secretary of ,health and ,human ,services and the ,secretary of the ,treasury1 #fe1jjj1jjj for fiscal year #bjbd1 to remain available through fiscal year #bjbi4 7b7 ,permitted purposes ,the purposes described in this subsection are the following purposes1 insofar as such purposes are to carry out the provisions of1 including the amendments made by1 this title3 7#a7 ,preparing1 drafting1 and issuing proposed and final regulations or interim regulations4 7#b7 ,preparing1 drafting1 and issuing guidance and public information4 7#c7 ,preparing1 drafting1 and publishing reports4 7#d7 ,enforcement of such provisions4 7#e7 ,reporting1 collection1 and analysis of data4 7#f7 ,other administrative duties necessary for implementation of such provisions4 7c7 ,transparency of implementation funds ,each ,secretary described in subsection 7a7 shall annually submit1 no later than ,september #ast of each year1 to the ,committees on ,energy and ,commerce1 on ,ways and ,means1 on ,education and ,workforce1 and on ,appropriations of the ,house of ,representatives and on the ,committees on ,health1 ,education1 ,labor1 and ,pensions and on ,appropriations of the ,senate a report on funds expended pursuant to funds appropriated under this section4 ,,ii ,reducing ,health ,care ,costs for ,patients #bja4 ,increasing transparency in generic drug applications 7a7 ,in general ,section #eje7;j77#c7 of the ,federal ,food1 ,drug1 and ,cosmetic ,act 7#ba ,u4,s4,c4 #cee7;j77#c77 is amended by adding at the end the following3 7,h7 7i7 ,upon request 7in controlled correspondence or an analogous process7 by a person that has submitted or intends to submit an abbreviated application under this subsection for a drug that is required by regulation to contain one or more of the same inactive ingredients in the same concentrations as the listed drug referred to1 or for which the ,secretary determines there is a scientific justification for an approach that is in vitro in whole or in part to be used to demonstrate bioequivalence for a drug if such a drug contains one or more of the same inactive ingredients in the same concentrations as the listed drug1 the ,secretary shall inform the person whether such drug is qualitatively and quantitatively the same as the listed drug4 ,the ,secretary may also provide such information to such a person on the ,secretary's own initiative during the review of an abbreviated application under this subsection for such drug4 7ii7 ,notwithstanding section #cja7;j71 if the ,secretary determines that such drug is not qualitatively or quantitatively the same as the listed drug1 the ,secretary shall identify and disclose to the person-- 7,i7 the ingredient or ingredients that cause such drug not to be qualitatively or quantitatively the same as the listed drug2 and 7,,ii7 for any ingredient for which there is an identified quantitative deviation1 the amount of such deviation4 7iii7 ,if the ,secretary determines that such drug is qualitatively and quantitatively the same as the listed drug1 the ,secretary shall not change or rescind such determination after the submission of an abbreviated application for such drug under this subsection unless-- 7,i7 the formulation of the listed drug has been changed and the ,secretary has determined that the prior listed drug formulation was withdrawn for reasons of safety or effectiveness2 or 7,,ii7 the ,secretary makes a written determination that the prior determination must be changed because an error has been identified4 7iv7 ,if the ,secretary makes a written determination described in clause 7iii77,,ii71 the ,secretary shall provide notice and a copy of the written determination to the person making the request under clause 7i74 7v7 ,the disclosures required by this subparagraph are disclosures authorized by law1 including for purposes of section #aije of title #ah1 ,united ,states ,code4 4 7b7 ,guidance 7#a7 ,in general ,not later than one year after the date of enactment of this ,act1 the ,secretary of ,health and ,human ,services shall issue draft guidance1 or update guidance1 describing how the ,secretary will determine whether a drug is qualitatively and quantitatively the same as the listed drug 7as such terms are used in section #eje7;j77#c77;,h7 of the ,federal ,food1 ,drug1 and ,cosmetic ,act1 as added by subsection 7a771 including with respect to assessing p,h adjusters4 7#b7 ,process ,in issuing guidance under this subsection1 the ,secretary of ,health and ,human ,services shall-- 7,a7 publish draft guidance2 7,b7 provide a period of at least #fj days for comment on the draft guidance2 and 7,c7 after considering any comments received and not later than one year after the close of the comment period on the draft guidance1 publish final guidance4 7c7 ,applicability ,section #eje7;j77#c77;,h7 of the ,federal ,food1 ,drug1 and ,cosmetic ,act1 as added by subsection 7a71 applies beginning on the date of enactment of this ,act1 irrespective of the date on which the guidance required by subsection 7b7 is finalized4 #bjb4 ,improving transparency and preventing the use of abusive spread pricing and related practices in ,medicaid 7a7 ,spread pricing 7#a7 ,in general ,section #aibg7;e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr-#h7;e77 is amended by adding at the end the following3 7#f7 ,pharmacy price reimbursement required 7,a7 ,in general ,a contract between the ,state and a pharmacy benefit manager 7in this paragraph referred to as a ,,pbm71 or a contract between the ,state and a designated entity 7as defined in subparagraph 7,c77 that includes provisions making the designated entity responsible for the administration of medical assistance consisting of covered outpatient drugs for individuals enrolled with the designated entity1 shall require that payment for such drugs and related administrative services 7as applicable71 including payments made by a ,,pbm on behalf of the ,state or designated entity1 is based on a pharmacy price reimbursement model under which-- 7i7 any payment made by the designated entity or the ,,pbm 7as applicable7 for such a drug-- 7,i7 is limited to-- 7aa7 ingredient cost2 and 7bb7 a professional dispensing fee that is not less than the professional dispensing fee that the ,state plan or waiver would pay if the plan or waiver was making the payment directly2 7,,ii7 is passed through in its entirety by the designated entity or ,,pbm to the pharmacy or provider that dispenses the drug and is not retroactively denied or reduced except as permitted or required under ,federal or ,state law or regulation2 and 7,,iii7 is made in a manner that is consistent with sections #ddg4ejb1 #ddg4eab1 #ddg4ead1 and #ddg4eah of title #db1 ,code of ,federal ,regulations 7or any successor regulation7 as if such requirements applied directly to the designated entity or the ,,pbm1 except that any payment by the designated entity or the ,,pbm for the ingredient cost of such a drug purchased by a covered entity 7as defined in subsection 7a77#e77;,b77 may exceed the actual acquisition cost 7as defined in section #ddg4ejb of title #db1 ,code of ,federal ,regulations 7or any successor regulation77 for such drug if-- 7aa7 such drug was subject to an agreement under section #cdj;,b of the ,public ,health ,service ,act2 7bb7 such payment for such cost of such drug does not exceed the maximum payment that would have been made by the designated entity or the ,,pbm for the ingredient cost of such drug had such drug not been purchased by such a covered entity2 and 7cc7 such covered entity reports to the ,secretary1 on an annual basis 7in a form and manner specified by the ,secretary7 and with respect to payments for such costs of such drugs so purchased by such covered entity that are in excess of the actual acquisition costs for such drugs1 the aggregate amount of such excess2 7ii7 payment to the designated entity or the ,,pbm 7as applicable7 for administrative services performed by the designated entity or ,,pbm is limited to an administrative fee that reflects the fair market value of providing such services2 7iii7 the designated entity or the ,,pbm 7as applicable7 makes available to the ,state1 and the ,secretary upon request1 all costs and payments related to covered outpatient drugs and accompanying administrative services incurred1 received1 or made by the designated entity or the ,,pbm1 including ingredient costs1 professional dispensing fees1 administrative fees1 post-sale and post-invoice fees1 discounts1 or related adjustments such as direct and indirect remuneration fees1 and any and all other remuneration2 and 7iv7 any form of spread pricing whereby any amount charged or claimed by the designated entity or the ,,pbm 7as applicable7 is in excess of the amount paid to the pharmacies by the designated entity or the ,,pbm1 including any post-sale or post-invoice fees1 discounts1 or related adjustments such as direct and indirect remuneration fees or assessments 7after allowing for a fair market administrative fee as described in clause 7ii771 is not allowable for purposes of claiming ,federal matching payments under this title4 7,b7 ,making certain information available ,the ,secretary shall publish1 not less frequently than on an annual basis1 information received by the ,secretary pursuant to subparagraph 7,a77i77,,iii77cc74 ,such information shall be so published in an electronic and searchable format1 such as through the #cdj;,b ,office of ,pharmacy ,affairs ,information ,system 7or a successor system74 7,c7 ,definitions ,in this paragraph3 7i7 ,designated entity ,the term designated entity means a managed care entity or other specified entity4 7ii7 ,managed care entity2 other specified entity ,the terms managed care entity and other specified entity have the meaning given such terms in section #aijc7m77#i77;,d74 4 7#b7 ,conforming amendments ,section #aijc7m7 of such ,act 7#db ,u4,s4,c4 #acif;b7m77 is amended-- 7,a7 in paragraph 7#b77;,a77xiii7-- 7i7 by striking and 7,,iii7 and inserting 7,,iii72 7ii7 by inserting before the period at the end the following3 1 and 7,,iv7 with respect to covered outpatient drugs and related administrative services 7as applicable7 provided by the entity 7or by a pharmacy benefit manager on behalf of the entity under a contract or other arrangement with the entity71 that payment for such drugs and related administrative services is based on a pharmacy price reimbursement model described in section #aibg7;e77#f77;,a72 and 7iii7 by moving the margin #b ems to the left2 and 7,b7 by adding at the end the following new paragraph3 7#aj7 ,no payment shall be made under this title to a ,state with respect to expenditures incurred by it for payment for services provided by an other specified entity 7as defined in paragraph 7#i77;,d77 unless the contract between the ,state and the entity for the provision of such services provides1 with respect to covered outpatient drugs and related administrative services 7as applicable7 provided by the entity 7or by a pharmacy benefit manager on behalf of the entity under a contract or other arrangement with the entity71 that payment for such drugs and related administrative services is based on a pharmacy price reimbursement model described in section #aibg7;e77#f77;,a74 4 7#c7 ,effective date ,the amendments made by this subsection apply to contracts between ,states and pharmacy benefit managers and designated entities 7as defined in section #aibg7;e77#f7 of the ,social ,security ,act1 as added by paragraph 7#a77 that have an effective date beginning on or after the date that is #ah months after the date of enactment of this ,act4 7b7 ,ensuring accurate payments to pharmacies under ,medicaid 7#a7 ,in general ,section #aibg7;f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr-#h7;f77 is amended-- 7,a7 by striking and after the semicolon at the end of paragraph 7#a77;,a77i7 and all that precedes it through 7#a7 and inserting the following3 7#a7 ,determining pharmacy actual acquisition costs ,the ,secretary shall conduct a survey of retail community pharmacy drug prices to determine the national average drug acquisition cost as follows3 7,a7 ,use of vendor ,the ,secretary may contract services for-- 7i7 with respect to retail community pharmacies1 the determination of retail survey prices of the national average drug acquisition cost for covered outpatient drugs based on a monthly survey of such pharmacies2 and 2 7,b7 by adding at the end of paragraph 7#a7 the following3 7,f7 ,survey reporting ,a ,state shall require that any retail community pharmacy in the ,state that receives any payment1 reimbursement1 administrative fee1 discount1 or rebate related to the dispensing of covered outpatient drugs to individuals receiving benefits under this title1 regardless of whether such payment1 reimbursement1 administrative fee1 discount1 or rebate is received from the ,state or a designated entity 7as defined in subsection 7e77#f77;,c77 directly or from a pharmacy benefit manager that has a contract with the ,state or a designated entity1 shall respond to surveys of retail prices conducted under this subsection4 7,g7 ,survey information ,information on national drug acquisition prices obtained under this paragraph shall be made publicly available in a timely manner following the collection of such information and shall include at least the following3 7i7 ,the monthly response rate to the survey including a list of pharmacies not in compliance with subparagraph 7,f74 7ii7 ,the sampling frame and number of pharmacies sampled monthly4 7iii7 ,information on price concessions to the pharmacy1 including discounts1 rebates1 and other price concessions1 to the extent that such information may be publicly released and is available during the survey period4 7,h7 ,report on specialty pharmacies ,not later than #a year after the date that this subparagraph takes effect1 the ,secretary shall submit to ,congress a report examining specialty drug coverage and reimbursement under this title1 including-- 7i7 a description of how ,state ,medicaid programs define specialty drugs and specialty pharmacies2 7ii7 the amount ,state ,medicaid programs pay for specialty drugs2 7iii7 how ,states and designated entities 7as defined in subsection 7e77#f77;,c77 determine payment for specialty drugs2 7iv7 the settings in which specialty drugs are dispensed to individuals receiving benefits under this title 7such as retail community pharmacies or specialty pharmacies72 7v7 the extent to which specialty drugs 7as defined by the respective ,states7 are captured in the national average drug acquisition cost survey 7or through another process72 7vi7 examples of specialty drug dispensing fees to support the services associated with dispensing such specialty drugs2 and 7vii7 recommendations as to whether specialty pharmacies should be included in the survey of retail prices to ensure national average drug acquisition costs capture drugs sold at specialty pharmacies1 and how such specialty pharmacies should be defined4 7,i7 ,enforcement ,at the discretion of the ,secretary1 the ,secretary 7acting through the ,inspector ,general and in collaboration with the ,administrator of the ,centers for ,medicare ,medicaid ,services7 may enforce non-compliance with this paragraph by a pharmacy through the establishment of penalties until compliance with this paragraph has been completed4 2 and 7,c7 in paragraph 7#b7-- 7i7 in subparagraph 7,a71 by inserting 7including payment rates under managed care organization as defined in section #aicb7;a77#a77;,b77i7 and ,p,i,h,ps and ,p,a,h,ps as defined in section #aijc7m77#i77;,d77iii77,i7 and 7,,ii71 respectively7 after under this title2 and 7ii7 in subparagraph 7,b71 by inserting 1 and the basis for such dispensing fees before the semicolon at the end4 7#b7 ,effective date ,the amendments made by this subsection shall take effect on the first day of the first quarter that begins on or after the date that is #ah months after the date of enactment of this ,act4 #bjc4 ,parity in ,medicare payments for hospital outpatient department services furnished off-campus 7a7 ,in general ,section #ahcc7t77#af7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t77#af77 is amended by adding at the end the following new subparagraph3 7,h7 ,parity in fee schedule amount for certain services furnished by an off-campus outpatient department of a provider 7i7 ,in general ,subject to clause 7iii71 in the case of specified ,,opd services 7as defined in clause 7v77 that are furnished during #bjbe or a subsequent year by an off-campus outpatient department of a provider 7as defined in clause 7iv77 7or1 in the case of an off-campus outpatient department of a provider that is a hospital described in section #ahhf7;d77#a77;,b77v71 or is located in a rural area or a health professional shortage area1 such services that are furnished during #bjbf or a subsequent year71 there shall be substituted for the amount otherwise determined under this subsection for such service and year an amount equal to the payment amount that would have been payable under the applicable payment system under this part 7other than under this subsection7 had such services been furnished by such a department subject to such payment system pursuant to paragraph 7#ba77;,c74 7ii7 ,not budget neutral implementation ,in making any budget neutrality adjustments under this subsection for #bjbe or a subsequent year1 the ,secretary shall not take into account the reduced expenditures that result from the application of this subparagraph4 7iii7 ,transition ,the ,secretary shall provide for a #d-year phase-in of the application of clause 7i71 with clause 7i7 being fully applicable for specified ,,opd services beginning with #bjbh 7or in the case of an off-campus outpatient department of a provider that is a hospital described in section #ahhf7;d77#a77;,b77v71 or is located in a rural area or a health professional shortage area1 beginning with #bjbi74 7iv7 ,off-campus department of a provider ,for purposes of this subparagraph1 the term off-campus outpatient department of a provider means a department of a provider 7as defined in section #dac4fe7;a77#b7 of title #db1 ,code of ,federal ,regulations7 that is not located-- 7,i7 on the campus 7as such term is defined in such section7 of such provider2 or 7,,ii7 within the distance 7described in such definition of campus7 from a remote location of a hospital facility 7as defined in such section74 7v7 ,other definitions ,for purposes of this subparagraph3 7,i7 ,designated ambulatory payment classification group ,the term designated ambulatory payment classification group means an ambulatory payment classification group for drug administration services4 7,,ii7 ,health professional shortage area ,the term health professional shortage area has the meaning given such term in section #ccb7;a77#a77;,a7 of the ,public ,health ,service ,act4 7,,iii7 ,rural area ,the term rural area has the meaning given such term in section #ahhf7;d77#b77;,d74 7,,iv7 ,specified ,,opd services ,the term specified ,,opd services means covered ,,opd services assigned to a designated ambulatory payment classification group4 4 7b7 ,implementation ,section #ahcc7t77#ab7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t77#ab77 is amended-- 7#a7 in subparagraph 7,d71 by striking and at the end2 7#b7 in subparagraph 7,e71 by striking the period at the end and inserting 2 and2 and 7#c7 by adding at the end the following new subparagraph3 7,f7 the determination of any payment amount under paragraph 7#af77;,h71 including the transition under clause 7iii7 of such paragraph4 4 #bjd4 ,requiring a separate identification number and an attestation for each off-campus outpatient department of a provider 7a7 ,in general ,section #ahcc7t7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t77 is amended by adding at the end the following new paragraph3 7#bc7 ,use of unique health identifiers2 attestation 7,a7 ,in general ,no payment may be made under this subsection 7or under an applicable payment system pursuant to paragraph 7#ba77 for items and services furnished on or after ,january #a1 #bjbf1 by an off-campus outpatient department of a provider 7as defined in subparagraph 7,c77 unless-- 7i7 such department has obtained1 and such items and services are billed under1 a standard unique health identifier for health care providers 7as described in section #aagc7;b77 that is separate from such identifier for such provider2 and 7ii7 such provider has submitted to the ,secretary1 during the #b-year period ending on the date such items and services are so furnished1 an attestation that such department is compliant with the requirements described in section #dac4fe of title #db1 ,code of ,federal ,regulations 7or a successor regulation74 7,b7 ,process for submission and review ,not later than #a year after the date of enactment of this paragraph1 the ,secretary shall1 through notice and comment rulemaking1 establish a process for each provider with an off-campus outpatient department of a provider to submit an attestation pursuant to subparagraph 7,a77ii71 and for the ,secretary to review each such attestation and determine1 through site visits1 remote audits1 or other means 7as determined appropriate by the ,secretary71 whether such department is compliant with the requirements described in such subparagraph4 7,c7 ,off-campus outpatient department of a provider defined ,for purposes of this paragraph1 the term off-campus outpatient department of a provider means a department of a provider 7as defined in section #dac4fe of title #db1 ,code of ,federal ,regulations1 or any successor regulation7 that is not located-- 7i7 on the campus 7as defined in such section7 of such provider2 or 7ii7 within the distance 7described in such definition of campus7 from a remote location of a hospital facility 7as defined in such section74 4 7b7 ,,hhs ,,oig analysis ,not later than ,january #a1 #bjcj1 the ,inspector ,general of the ,department of ,health and ,human ,services shall submit to ,congress-- 7#a7 an analysis of the process established by the ,secretary of ,health and ,human ,services to conduct the reviews and determinations described in section #ahcc7t77#bc77;,b7 of the ,social ,security ,act1 as added by subsection 7a7 of this section2 and 7#b7 recommendations based on such analysis1 as the ,inspector ,general determines appropriate4 ,,iii ,supporting ,patients1 ,health ,care ,workers1 ,community ,health ,centers1 and ,hospitals #cja4 ,extension for community health centers1 the national health service corps1 and teaching health centers that operate ,,gme programs 7a7 ,teaching health centers that operate graduate medical education programs 7#a7 ,addition to capped amounts for fiscal years #bjbd and #bjbe ,paragraph 7#b7 of section #cdj;,h7b7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bef;h7b77 is amended by adding at the end the following3 7,c7 ,addition ,notwithstanding any provision of this section1 for each of fiscal years #bjbd and #bjbe1 the ,secretary may use any amounts made available in any fiscal year to carry out this section 7including amounts recouped under subsection 7f77 to make payments described in paragraphs 7#a77;,a7 and 7#a77;,b71 in addition to the total amount of funds appropriated under subsection 7g74 4 7#b7 ,reconciliation ,section #cdj;,h7f7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bef;h7f77 is amended-- 7,a7 by striking ,the ,secretary shall determine and inserting the following3 7#a7 ,determination ,the ,secretary shall determine 2 and 7,b7 by adding at the end the following3 7#b7 ,annual report to ,congress ,for each fiscal year1 the ,secretary shall submit to the ,committee on ,energy and ,commerce of the ,house of ,representatives and the ,committee on ,health1 ,education1 ,labor1 and ,pensions of the ,senate a report specifying-- 7,a7 the total amount of funds recouped under paragraph 7#a72 7,b7 the rationale for the funds being recouped2 and 7,c7 in the case of the reports for each of fiscal years #bjbd and #bjbe1 the total amount of funds recouped under paragraph 7#a7 that were used pursuant to subsection 7b77#b77;,c7 to adjust total payment amounts above the total amounts appropriated under subsection 7g74 4 7#c7 ,funding ,section #cdj;,h7g7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bef;h7g77 is amended-- 7,a7 by amending paragraph 7#a7 to read as follows3 7#a7 ,in general ,to carry out this section1 there are appropriated such sums as may be necessary1 not to exceed-- 7,a7 #bcj1jjj1jjj1 for the period of fiscal years #bjaa through #bjae2 7,b7 #fj1jjj1jjj for each of fiscal years #bjaf and #bjag2 7,c7 #abf1ejj1jjj for each of fiscal years #bjah through #bjbc2 7,d7 #af1fce1faf for the period beginning on ,october #a1 #bjbc1 and ending on ,november #ag1 #bjbc2 7,e7 #ba1hcd1bdg for the period beginning on ,november #ah1 #bjbc1 and ending on ,january #ai1 #bjbd2 7,f7 #acf1ecj1acg for the period beginning on ,january #bj1 #bjbd1 and ending on ,september #cj1 #bjbd2 7,g7 #age1jjj1jjj for fiscal year #bjbe2 7,h7 #bbe1jjj1jjj for each of fiscal years #bjbf and #bjbg2 and 7,i7 #cjj1jjj1jjj for each of fiscal years #bjbh1 #bjbi1 and #bjcj4 2 and 7,b7 by adding at the end the following3 7#c7 ,availability ,the amounts made available under paragraph 7#a7 shall remain available until expended4 4 7b7 ,extension for community health centers ,section #ajejc7;b77#a77;,f7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #bed;b-#b7;b77#a77;,f77 is amended-- 7#a7 by striking and before #fij1daj1iei2 and 7#b7 by inserting 1 #c1ahc1efa1fdd for the period beginning on ,january #bj1 #bjbd1 and ending on ,september #cj1 #bjbd1 #d1djj1jjj1jjj for fiscal year #bjbe1 and #a1aji1jjj1jjj for the period beginning ,october #a1 #bjbe1 and ending ,december #ca1 #bjbe before the semicolon at the end4 7c7 ,extension for the ,national ,health ,service ,corps ,section #ajejc7;b77#b7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #bed;b-#b7;b77#b77 is amended-- 7#a7 in subparagraph 7,h71 by striking and at the end2 7#b7 in subparagraph 7,i71 by striking the period at the end and inserting 2 and2 and 7#c7 by adding at the end the following3 7,j7 #bee1gbf1jbh for the period beginning on ,january #bj1 #bjbd1 and ending on ,september #cj1 #bjbd1 #cej1jjj1jjj for fiscal year #bjbe1 and #hh1bai1agh for the period beginning ,october #a1 #bjbe1 and ending ,december #ca1 #bjbe4 4 7d7 ,government ,accountability ,office report 7#a7 ,in general ,not later than one year after the date of enactment of this ,act1 the ,comptroller ,general of the ,united ,states shall submit to the ,committee on ,energy and ,commerce of the ,house of ,representatives and the ,committee on ,health1 ,education1 ,labor1 and ,pensions of the ,senate a report assessing the effectiveness of the ,national ,health ,service ,corps at attracting health care professionals to ,h,p,s,as1 including by-- 7,a7 assessing the metrics used by the ,health ,resources and ,services ,administration in evaluating the program2 7,b7 comparing the retention rates of ,,nhsc participants in the ,h,p,s,as where they completed their period of obligated service to the retention rate of non-,,nhsc participants in the corresponding ,h,p,s,as2 7,c7 comparing the retention rates of ,,nhsc participants in the ,h,p,s,as where they completed their period of obligated service to the retention rates of ,,nhsc participants in ,h,p,s,as other than those where they completed their period of obligated service2 7,d7 identifying factors that influence a ,,nhsc participant's decision to practice in a ,,hpsa other than the ,,hpsa where they completed their period of obligated service2 7,e7 identifying factors other than participation in the ,national ,health ,service ,corps ,scholarship and ,loan ,repayment ,programs that attract health care professionals to a ,,hpsa2 7,f7 assessing the impact the ,national ,health ,service ,corps has on wages for health care professionals in a ,,hpsa2 and 7,g7 comparing the distribution of ,,nhsc participants across ,h,p,s,as1 including a comparison of rural versus non-rural ,h,p,s,as4 7#b7 ,definition ,in this section3 7,a7 ,the term ,,hpsa means a health professional shortage area designated under section #ccb of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bed;e74 7,b7 ,the term ,,nhsc participant means a ,national ,health ,service ,corps member participating in the ,national ,health ,service ,corps ,scholarship or ,loan ,repayment ,program4 7e7 ,application of provisions ,amounts appropriated pursuant to the amendments made by this section shall be subject to the requirements contained in ,public ,law #aag-cbh for funds for programs authorized under sections #ccj through #cdj of the ,public ,health ,service ,act4 7f7 ,conforming amendment ,paragraph 7#d7 of section #cjad7;h7 of title #ah1 ,united ,states ,code1 is amended by striking and section #bcba7;d7 of the ,continuing ,appropriations ,act1 #bjbd and ,other ,extensions ,act and inserting section #bcba7;d7 of the ,continuing ,appropriations ,act1 #bjbd and ,other ,extensions ,act1 and section #cja7;e7 of the ,lower ,costs1 ,more ,transparency ,act4 #cjb4 ,extension of special diabetes programs 7a7 ,extension of special diabetes programs for type i diabetes ,section #ccj;,b7b77#b7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bed;c-#b7;b77#b77 is amended-- 7#a7 in subparagraph 7,d71 by striking and at the end2 7#b7 in subparagraph 7,e71 by striking the period at the end and inserting a semicolon2 and 7#c7 by adding at the end the following3 7,f7 #abd1chc1efb for the period beginning on ,january #bj1 #bjbd1 and ending on ,september #cj1 #bjbd1 to remain available until expended2 7,g7 #agj1jjj1jjj for fiscal year #bjbe1 to remain available until expended2 and 7,h7 #db1hdi1cae for the period beginning ,october #a1 #bjbe1 and ending ,december #ca1 #bjbe1 to remain available until expended4 4 7b7 ,extending funding for special diabetes programs for ,indians ,section #ccj;,c7c77#b7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bed;c-#c7;c77#b77 is amended-- 7#a7 in subparagraph 7,d71 by striking and at the end2 7#b7 in subparagraph 7,e71 by striking the period at the end and inserting a semicolon2 and 7#c7 by adding at the end the following3 7,f7 #abd1chc1efb for the period beginning on ,january #bj1 #bjbd1 and ending on ,september #cj1 #bjbd1 to remain available until expended2 7,g7 #agj1jjj1jjj for fiscal year #bjbe1 to remain available until expended2 and 7,h7 #db1hdi1cae for the period beginning ,october #a1 #bjbe1 and ending ,december #ca1 #bjbe1 to remain available until expended4 4 #cjc4 ,delaying certain disproportionate share payment cuts ,section #aibc7;f77#g77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr-#d7;f77#g77;,a77 is amended-- 7#a7 in clause 7i7-- 7,a7 by striking ,for the period beginning ,january #bj1 #bjbd1 and ending ,september #cj1 #bjbd1 and for each of fiscal years #bjbe and inserting ,for each of fiscal years #bjbf2 and 7,b7 by striking or period each place such term appears2 and 7#b7 in clause 7ii71 by striking for the period beginning ,january #bj1 #bjbd1 and ending ,september #cj1 #bjbd1 and for each of fiscal years #bjbe and inserting for each of fiscal years #bjbf4 #cjd4 ,medicaid improvement fund ,section #aida7;b77#c77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifw-#a7;b77#c77;,a77 is amended by striking #f1ceg1aag1haj and inserting #j4 ,,iv ,increasing access to quality health data and lowering hidden fees #dja4 ,increasing ,plan ,fiduciaries' ,access to ,health ,data 7a7 ,plan fiduciary access to information 7#a7 ,in general ,paragraph 7#b7 of section #djh7;b7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aajh7;b77 is amended by adding at the end the following new subparagraph3 7,c7 ,no contract or arrangement for services between a group health plan and any other entity1 including a health care provider 7including a health care facility71 network or association of providers1 service provider offering access to a network of providers1 third-party administrator1 or pharmacy benefit manager1 is reasonable within the meaning of this paragraph unless such contract or arrangement-- 7i7 allows the responsible plan fiduciary 7as defined in subparagraph 7,b77ii77,i77ee77 to audit or review all de-identified claims and encounter information or data described in section #gbd7;a77#a77;,b7 to-- 7,i7 ensure that such entity complies with the terms of the plan and any applicable law2 and 7,,ii7 determine the reasonableness of compensation received by such entity2 and 7ii7 does not-- 7,i7 unreasonably limit the number of audits permitted during a given period of time2 7,,ii7 limit the number of de-identified claims and encounter information or data that the responsible plan fiduciary may access during an audit2 7,,iii7 limit the disclosure of pricing terms for value-based payment arrangements or capitated payment arrangements1 including-- 7aa7 payment calculations and formulas2 7bb7 quality measures2 7cc7 contract terms2 7dd7 payment amounts2 7ee7 measurement periods for all incentives2 and 7ff7 other payment methodologies used by an entity1 including a health care provider 7including a health care facility71 network or association of providers1 service provider offering access to a network of providers1 third-party administrator1 or pharmacy benefit manager2 7,,iv7 limit the disclosure of overpayments and overpayment recovery terms2 7,v7 limit the right of the responsible plan fiduciary to select an auditor2 7,,vi7 otherwise limit or unduly delay by greater than #fj calendar days after the date of request the responsible plan fiduciary from auditing all de-identified claims and encounter information or data2 or 7,,vii7 permit the entity to charge a fee beyond the reasonable direct costs to provide the required information and otherwise comply and assist with an audit request4 4 7#b7 ,civil enforcement 7,a7 ,in general ,subsection 7c7 of section #ejb of such ,act 7#bi ,u4,s4,c4 #aacb7 is amended by adding at the end the following new paragraph3 7#ac7 ,in the case of an agreement between a group health plan and a health care provider 7including a health care facility71 network or association of providers1 service provider offering access to a network of providers1 third-party administrator1 or pharmacy benefit manager1 that violates the provisions of section #gbd1 the ,secretary may assess a civil penalty against such provider1 network or association1 service provider offering access to a network of providers1 third-party administrator1 pharmacy benefit manager1 or other service provider in the amount of #aj1jjj for each day during which such violation continues4 ,such penalty shall be in addition to other penalties as may be prescribed by law4 4 7,b7 ,conforming amendment ,paragraph 7#f7 of section #ejb7;a7 of such ,act is amended by striking or 7#i7 and inserting 7#i71 or 7#ac74 7#c7 ,existing provisions void ,section #daj of such ,act is amended by adding at the end the following new subsection3 7c7 ,any provision in an agreement or instrument shall be void as against public policy if such provision-- 7#a7 unduly delays or limits a plan fiduciary from accessing the de-identified claims and encounter information or data described in section #gbd7;a77#a77;,b72 or 7#b7 violates the requirements of section #djh7;b77#b77;,c74 4 7b7 ,updated attestation for price and quality information ,section #gbd7;a77#c7 of the ,employee ,retirement ,income ,security ,act 7#bi ,u4,s4,c4 #aahem7a77#c77 is amended to read as follows3 7#c7 ,attestation 7,a7 ,in general ,subject to subparagraph 7,c71 the plan fiduciary of a group health plan or health insurance issuer offering group health insurance coverage shall annually submit to the ,secretary an attestation that such plan or issuer of such coverage is in compliance with the requirements of this subsection4 ,such attestation shall also include a statement verifying that-- 7i7 the information or data described under subparagraphs 7,a7 and 7,b7 of paragraph 7#a7 is available upon request and provided to the plan fiduciary1 the plan administrator1 or the issuer in a timely manner2 and 7ii7 there are no terms in the agreement under such paragraph 7#a7 that directly or indirectly restrict or unduly delay a plan fiduciary1 the plan administrator1 or the issuer from auditing1 reviewing1 or otherwise accessing such information1 except as permitted under section #djh7;b77#b77;,c74 7,b7 ,limitation on submission ,subject to clause 7ii71 a group health plan or issuer offering group health insurance coverage may not enter into an agreement with a third-party administrator or other service provider to submit the attestation required under subparagraph 7,a74 7,c7 ,exception ,in the case of a group health plan or issuer offering group health insurance coverage that is unable to obtain the information or data needed to submit the attestation required under subparagraph 7,a71 such plan or issuer may submit a written statement in lieu of such attestation that includes-- 7i7 an explanation of why such plan or issuer was unsuccessful in obtaining such information or data1 including whether such plan or issuer was limited or prevented from auditing1 reviewing1 or otherwise accessing such information or data2 7ii7 a description of the efforts made by the plan fiduciary to remove any gag clause provisions from the agreement under paragraph 7#a72 and 7iii7 a description of any response by the third-party administrator or other service provider with respect to efforts to comply with the attestation requirement under subparagraph 7,a74 4 7c7 ,report on plan assets ,not later than #a year after the date of enactment of this ,act1 the ,secretary of ,labor shall submit to the ,committee on ,education and the ,workforce of the ,house of ,representatives and the ,committee on ,health1 ,education1 ,labor1 and ,pensions of the ,senate a report on the status of de-identified claims and encounter information or data described in section #gbd7;a77#a77;,b7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aahem71 including information on the following3 7#a7 ,whether changes to regulations or guidance would permit such information or data to be deemed a group health plan asset 7as defined under section #c7db7 of such ,act74 7#b7 ,whether restrictions on the ability of a plan fiduciary to access such information or data violates a requirement of current law4 7#c7 ,the existing regulatory authority of the ,secretary to clarify whether such information or data is the property of a group health plan1 rather than a service provider4 7#d7 ,legislative recommendations to establish that such information or data related to a plan belongs to a group health plan and is handled in the best interests of plan participants and beneficiaries4 7d7 ,effective date ,the amendments made by subsections 7a7 and 7b7 shall apply with respect to a plan beginning with the first plan year that begins on or after the date that is #a year after the date of enactment of this ,act4 #djb4 ,hidden ,fees ,disclosure ,requirements 7a7 ,clarification of the application of fee disclosure requirements to covered service providers 7#a7 ,services ,clause 7ii77,i77bb7 of section #djh7;b77#b77;,b7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aajh7;b77#b77;,b77 is amended-- 7,a7 in subitem 7,,aa7 by striking ,brokerage services1 and inserting ,services 7including brokerage services712 and 7,b7 in subitem 7,,bb7-- 7i7 by striking ,consulting1 and inserting ,other services12 and 7ii7 by inserting any of the following3 before plan design4 7#b7 ,disclosures ,clause 7iii77,,iii7 of section #djh7;b77#b77;,b7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aajh7;b77#b77;,b77 is amended by striking 1 either in the aggregate or by service1 and inserting by service4 7b7 ,strengthening disclosure requirements with respect to pharmacy benefit managers and third party administrators for group health plans 7#a7 ,certain arrangements for pharmacy benefit manager services considered as indirect 7,a7 ,in general ,clause 7i7 of section #djh7;b77#b77;,b7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aajh7;b77#b77;,b77 is amended-- 7i7 by striking requirements of this clause and inserting requirements of this subparagraph2 and 7ii7 by adding at the end the following3 ,for purposes of applying section #djf7;a77#a77;,c7 with respect to a transaction described under this subparagraph1 a contract or arrangement for services between a covered plan and a health insurance issuer providing health insurance coverage in connection with the covered plan in which the health insurance issuer contracts1 in connection with such plan1 with a service provider for pharmacy benefit management services shall be considered to constitute an indirect furnishing of goods1 services1 or facilities between the plan and the service provider acting as the party in interest44 7,b7 ,health insurance issuer and health insurance coverage defined ,clause 7ii77,i77aa7 of section #djh7;b77#b77;,b7 of such ,act 7#bi ,u4,s4,c4 #aajh7;b77#b77;,b77 is amended by inserting before the period at the end and the terms health insurance coverage and health insurance issuer have the meanings given such terms in section #gcc7;b74 7,c7 ,technical amendment ,clause 7ii77,i77aa7 of section #djh7;b77#b77;,b7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aajh7;b77#b77;,b77 is further amended by inserting in after defined4 7#b7 ,specific disclosure requirements with respect to pharmacy benefit management services 7,a7 ,in general ,clause 7iii7 of section #djh7;b77#b77;,b7 of such ,act 7#bi ,u4,s4,c4 #aajh7;b77#b77;,b77 is amended by adding at the end the following3 7,,vii7 ,with respect to a contract or arrangement with the covered plan in connection with the provision of pharmacy benefit management services1 as part of the description required under subclauses 7,,iii7 and 7,,iv7-- 7aa7 all compensation described in clause 7ii77,i77dd77,,aa71 including fees1 rebates1 alternative discounts1 co-payment offsets1 and other remuneration expected to be received by the covered service provider1 an affiliate1 or a subcontractor from a pharmaceutical manufacturer1 distributor1 rebate aggregator1 accumulator1 and maximizer1 group purchasing organization1 or any other third party2 7bb7 the amount and form of any rebates1 discounts1 or price concessions1 including the amount expected to be passed through to the plan sponsor or the participants and beneficiaries under the covered plan2 7cc7 all compensation expected to be received by the covered service provider1 an affiliate1 or a subcontractor as a result of paying a lower amount for the drug than the amount charged as a copayment1 coinsurance amount1 or deductible2 7dd7 all compensation expected to be received by the covered service provider1 an affiliate1 or a subcontractor as a result of paying pharmacies less than what is charged the health plan1 plan sponsor1 or participants and beneficiaries under the covered plan2 and 7ee7 all compensation expected to be received by the covered service provider1 an affiliate1 or a subcontractor from drug manufacturers and any other third party in exchange for-- 7,,aa7 administering1 invoicing1 allocating1 or collecting rebates related to the covered plan2 7,,bb7 providing business services and activities1 including providing access to drug utilization data2 7,,cc7 keeping a percentage of the list price of a drug2 or 7,,dd7 any other reason related to the role of a covered service provider as a conduit between the drug manufacturers or any other third party and the covered plan4 4 7,b7 ,annual disclosure ,clause 7v7 of section #djh7;b77#b77;,b7 of such ,act 7#bi ,u4,s4,c4 #aajh7;b77#b77;,b77 is amended by adding at the end the following3 7,,iii7 ,a covered service provider1 with respect to a contract or arrangement with the covered plan in connection with providing pharmacy benefit management services1 shall disclose1 on an annual basis not later than #fj days after the beginning of the current plan year1 to a responsible plan fiduciary1 in writing1 the following with respect to the twelve months preceding the current plan year3 7aa7 ,all direct compensation described in subclause 7,,iii7 of clause 7iii7 and indirect compensation described in subclause 7,,iv7 of clause 7iii7 received by the covered service provider 7including such compensation described in subclause 7,,vii7 of clause 7iii774 7bb7 ,the total gross spending by the covered plan on drugs 7excluding rebates1 discounts1 or other price concessions74 7cc7 ,the total net spending by the covered plan on drugs4 7dd7 ,the total gross spending at all pharmacies wholly or partially owned by the covered service provider or any entity affiliated with the covered service provider1 including mail-order1 specialty and retail pharmacies1 with a breakdown by individual pharmacy location4 7ee7 ,the aggregate amount of clawback from such pharmacies1 including mail-order1 specialty1 and retail pharmacies4 7,,aa7 categorical explanations 7grouped by the reason for clawback1 such as contractual true-up provisions1 overpayments1 or non-covered medication dispensed1 and including information on the amount in each category that was passed through to the covered plan and to participants and beneficiaries of the covered plan72 or 7,,bb7 individual explanations for such clawbacks4 7ff7 ,total aggregate amounts of fees collected by the covered service provider1 an affiliate1 or a subcontractor in connection with the provision of pharmacy benefit management services to the covered plan4 7gg7 ,any other information specified by the ,secretary through regulations or guidance that may be necessary for a responsible plan fiduciary to consider the merits of the contract or arrangement with the covered service provider and any conflicts of interest that may exist4 4 7,c7 ,pharmacy benefit management services defined ,clause 7ii77,i7 of section #djh7;b77#b77;,b7 of such ,act 7#bi ,u4,s4,c4 #aajh7;b77#b77;,b77 is amended by adding at the end the following3 7gg7 ,the term pharmacy benefit management services includes any services provided by a covered service provider to a covered plan with respect to the administration of prescription drug benefits under the covered plan1 including-- 7,,aa7 processing and payment of claims2 7,,bb7 design of pharmacy networks2 7,,cc7 negotiation1 aggregation1 and distribution of rebates1 discounts1 and other price concessions2 7,,dd7 formulary design and maintenance2 7,,ee7 operation of pharmacies 7whether retail1 mail order1 specialty drug1 or otherwise72 7,,ff7 recordkeeping2 7,,gg7 utilization review2 7,,hh7 adjudication of claims2 and 7,,ii7 any other services specified by the ,secretary through guidance or rulemaking4 4 7,d7 ,clawback defined ,clause 7ii77,i7 of section #djh7;b77#b77;,b7 of such ,act 7#bi ,u4,s4,c4 #aajh7;b77#b77;,b771 as amended by subparagraph 7,c71 is amended by adding at the end the following3 7hh7 ,the term clawback means amounts collected by a provider of pharmacy benefit management services from a pharmacy for copayments collected from a participant or beneficiary in excess of the contracted rate4 4 7#c7 ,specific disclosure requirements with respect to third party administration services for group health plans 7,a7 ,in general ,clause 7iii7 of section #djh7;b77#b77;,b7 of such ,act 7#bi ,u4,s4,c4 #aajh7;b77#b77;,b771 as amended by paragraph 7#b77;,a71 is further amended by adding at the end the following3 7,,viii7 ,with respect to a contract or arrangement with the covered plan in connection with the provision of third party administration services for group health plans1 as part of the description required under subclauses 7,,iii7 and 7,,iv7-- 7aa7 the amount and form of any rebates1 discounts1 savings fees1 refunds1 or amounts received from providers and facilities1 including the amounts that will be retained by the covered service provider as a fee2 7bb7 the amount and form of fees expected to be received from other service providers in relation to the covered plan1 including the amounts that will be retained by the covered service provider as a fee2 and 7cc7 the amount and form of expected recoveries by the covered service provider1 including the amounts that will be retained by the covered service provider as a fee 7disaggregated by category71 as a result of-- 7,,aa7 overpayments2 7,,bb7 erroneous payments2 7,,cc7 uncashed checks or incomplete payments2 7,,dd7 billing errors2 7,,ee7 subrogation2 7,,ff7 fraud2 or 7,,gg7 any other reason on behalf of the covered plan4 4 7,b7 ,annual disclosure ,clause 7v7 of section #djh7;b77#b77;,b7 of such ,act 7#bi ,u4,s4,c4 #aajh7;b77#b77;,b771 as amended by paragraph 7#b77;,b71 is amended by adding at the end the following3 7,,iv7 ,a covered service provider1 with respect to a contract or arrangement with the covered plan in connection with providing third party administration services for group health plans1 shall disclose1 on an annual basis not later than #fj days after the beginning of the current plan year1 to a responsible plan fiduciary1 in writing1 the following with respect to the twelve months preceding the current plan year3 7aa7 ,all direct compensation described in subclause 7,,iii7 of clause 7iii74 7bb7 ,all indirect compensation described in subclause 7,,iv7 of clause 7iii7 received by the covered service provider1 an affiliate1 or a subcontractor 7including such compensation described in subclause 7,,viii7 of clause 7iii774 7cc7 ,the aggregate amount for which the covered service provider1 an affiliate1 or a subcontractor received indirect compensation and the estimated amount of cost-sharing incurred by plan participants and beneficiaries as a result4 7dd7 ,the total gross spending by the covered plan on all costs and fees arising under or paid under the administrative services agreement with the covered service provider 7not including any amounts described in items 7aa7 through 7cc7 of clause 7iii77,,viii774 7ee7 ,the total net spending by the covered plan on all costs and fees arising under or paid under the administrative services agreement with the covered service provider4 7ff7 ,the aggregate fees collected by the covered service provider1 an affiliate1 or a subcontractor4 7gg7 ,any other information specified by the ,secretary through regulations or guidance that may be necessary for a responsible plan fiduciary to consider the merits of the contract or arrangement with the covered service provider and any conflicts of interest that may exist4 4 7,c7 ,third party administration services for group health plans defined ,clause 7ii77,i7 of section #djh7;b77#b77;,b7 of such ,act 7#bi ,u4,s4,c4 #aajh7;b77#b77;,b771 as amended by paragraph 7#b77;,c71 is amended by adding at the end the following3 7ii7 ,the term third party administration services for group health plans includes any services provided by a covered service provider1 an affiliate1 or a subcontractor to a covered plan with respect to the administration of health benefits under the covered plan1 including-- 7,,aa7 the processing1 repricing1 and payment of claims2 7,,bb7 design1 creation1 and maintenance of provider networks2 7,,cc7 negotiation of discounts off gross rates2 7,,dd7 benefit and plan design2 7,,ee7 negotiation of payment rates2 7,,ff7 recordkeeping2 7,,gg7 utilization review2 7,,hh7 adjudication of claims2 7,,ii7 regulatory compliance2 and 7,,jj7 any other services set forth in an administrative services agreement or similar agreement or specified by the ,secretary through rulemaking4 4 7#d7 ,rule of construction ,nothing in the amendments made by this section shall be construed to imply that a practice in relation to which a covered service provider is required to provide information as a result of such amendments is permissible under ,federal law4 7#e7 ,effective date ,no contract or arrangement entered into prior to ,january #a1 #bjbe1 shall be subject to the requirements of subsection 7b74 7c7 ,privacy requirements ,section #djh7;b77#b7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aajh7;b77#b771 as amended by section #dja1 is further amended by adding at the end the following3 7,d7 ,privacy requirements ,covered service providers shall provide information under subparagraph 7,b7 in a manner consistent with the privacy1 security1 and breach notification regulations promulgated under section #acdjb7;a7 of the ,health ,information ,technology for ,clinical ,health ,act 7#db ,u4,s4,c4 #agicb7;a771 and consistent with the ,,hipaa privacy regulations 7as defined in section #aahj7;b77#c7 of the ,social ,security ,act7 and shall restrict the use and disclosure of such information according to such privacy1 security1 and breach notification regulations and such ,,hipaa privacy regulations4 7,e7 ,disclosure and redisclosure 7i7 ,limitation to business associates ,a responsible plan fiduciary receiving information disclosed under subparagraph 7,b7 may disclose such information only to the entity from which the information was received1 the group health plan for which the information pertains1 or to that entity's business associates as defined in section #afj4ajc of title #de1 ,code of ,federal ,regulations 7or successor regulations7 or as permitted by the ,,hipaa ,privacy ,rule 7#de ,,cfr parts #afj and #afd1 subparts ,a and ,e74 7ii7 ,clarification regarding public disclosure of information ,nothing in this section shall prevent a group health plan or health insurance issuer offering group health insurance coverage1 or a covered service provider1 from placing reasonable restrictions on the public disclosure of the information described in this subparagraph1 except that such plan1 issuer1 or entity may not restrict disclosure of such information to the ,department of ,labor4 7,f7 ,additional privacy requirements 7i7 ,in general ,covered service providers shall ensure that information provided under subparagraph 7,b7 contains only summary health information1 as defined in section #afd4ejd7;a7 of title #de1 ,code of ,federal ,regulations 7or successor regulations74 7ii7 ,restrictions ,a group health plan must comply with section #afd4ejd7;f7 of title #de1 ,code of ,federal ,regulations and a responsible plan administrator who is a plan sponsor must act in accordance with the terms of the agreement described in such section4 7,g7 ,rule of construction ,nothing in this section shall be construed to modify the requirements for the creation1 receipt1 maintenance1 or transmission of protected health information under the ,,hipaa privacy regulations 7as defined in section #aahj7;b77#c7 of the ,social ,security ,act74 4 7d7 ,implementation ,not later than #a year after the date of enactment of this ,act1 the ,secretary of ,labor shall issue notice and comment rulemaking as necessary to implement the provisions of this section4 ,the ,secretary shall ensure that such rulemaking-- 7#a7 accounts for the varied compensation practices of covered service providers 7as defined under section #djh7;b77#b77;,b72 and 7#b7 establishes standards for the disclosure of expected compensation by such covered service providers4 #djc4 ,prescription drug price information requirement 7a7 ,,phsa 7#a7 ,in general ,part ,d of title ,,xxvii of the ,public ,health ,service ,act1 as amended by section #ajf1 is further amended by adding at the end the following new section3 #bgii;,a-#ab4 ,information on prescription drugs 7a7 ,in general ,a group health plan or a health insurance issuer offering group or individual health insurance coverage shall-- 7#a7 not restrict1 directly or indirectly1 any pharmacy that dispenses a prescription drug to an enrollee in the plan or coverage from informing 7or penalize such pharmacy for informing7 an enrollee of any differential between the enrollee's out-of-pocket cost under the plan or coverage with respect to acquisition of the drug and the amount an individual would pay for acquisition of the drug without using any group health plan or health insurance coverage2 and 7#b7 ensure that any entity that provides pharmacy benefits management services under a contract with any such health plan or health insurance coverage does not1 with respect to such plan or coverage1 restrict1 directly or indirectly1 a pharmacy that dispenses a prescription drug from informing 7or penalize such pharmacy for informing7 an enrollee of any differential between the enrollee's out-of-pocket cost under such plan or coverage with respect to acquisition of the drug and the amount an individual would pay for acquisition of the drug without using any group health plan or health insurance coverage4 7b7 ,definition ,for purposes of this section1 the term out-of-pocket cost1 with respect to acquisition of a drug1 means the amount to be paid by the enrollee under the plan or coverage1 including any cost-sharing 7including any deductible1 copayment1 or coinsurance7 and1 as determined by the ,secretary1 any other expenditure4 4 7#b7 ,conforming amendment ,section #bgbi of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#bi7 is amended by adding at the end the following new subsection3 7c7 ,sunset ,the preceding provisions of this section shall not apply beginning on the date of the enactment of this subsection4 4 7b7 ,,erisa 7#a7 ,in general ,subpart ,b of part #g of ,subtitle ,b of title ,i of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aahe et seq471 as amended by section #ajf1 is further amended by adding at the end the following new section3 #gbg4 ,information on prescription drugs 7a7 ,in general ,a group health plan or a health insurance issuer offering group health insurance coverage shall-- 7#a7 not restrict1 directly or indirectly1 any pharmacy that dispenses a prescription drug to a participant or beneficiary in the plan or coverage from informing 7or penalize such pharmacy for informing7 a participant or beneficiary of any differential between the participant's or beneficiary's out-of-pocket cost under the plan or coverage with respect to acquisition of the drug and the amount an individual would pay for acquisition of the drug without using any group health plan or health insurance coverage2 and 7#b7 ensure that any entity that provides pharmacy benefits management services under a contract with any such health plan or health insurance coverage does not1 with respect to such plan or coverage1 restrict1 directly or indirectly1 a pharmacy that dispenses a prescription drug from informing 7or penalize such pharmacy for informing7 a participant or beneficiary of any differential between the participant's or beneficiary's out-of-pocket cost under such plan or coverage with respect to acquisition of the drug and the amount an individual would pay for acquisition of the drug without using any group health plan or health insurance coverage4 7b7 ,definition ,for purposes of this section1 the term out-of-pocket cost1 with respect to acquisition of a drug1 means the amount to be paid by the participant or beneficiary under the plan or coverage1 including any cost-sharing 7including any deductible1 copayment1 or coinsurance7 and1 as determined by the ,secretary1 any other expenditure4 4 7#b7 ,clerical amendment ,the table of contents in section #a of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #ajja et seq471 as amended by section #ajf1 is further amended by inserting after the item relating to section #gbf the following new item3 ,sec4 #gbg4 ,information on prescription drugs4 4 7c7 ,,irc 7#a7 ,in general ,subchapter ,b of chapter #ajj of the ,internal ,revenue ,code of #aihf1 as amended by section #ajf1 is further amended by adding at the end the following3 #ihbg4 ,information on prescription drugs 7a7 ,in general ,a group health plan shall-- 7#a7 not restrict1 directly or indirectly1 any pharmacy that dispenses a prescription drug to a participant or beneficiary in the plan from informing 7or penalize such pharmacy for informing7 a participant or beneficiary of any differential between the participant's or beneficiary's out-of-pocket cost under the plan with respect to acquisition of the drug and the amount an individual would pay for acquisition of the drug without using any group health plan or health insurance coverage2 and 7#b7 ensure that any entity that provides pharmacy benefits management services under a contract with any such plan does not1 with respect to such plan or coverage1 restrict1 directly or indirectly1 a pharmacy that dispenses a prescription drug from informing 7or penalize such pharmacy for informing7 a participant or beneficiary of any differential between the participant's or beneficiary's out-of-pocket cost under the plan with respect to acquisition of the drug and the amount an individual would pay for acquisition of the drug without using any group health plan or health insurance coverage4 7b7 ,definition ,for purposes of this section1 the term out-of-pocket cost1 with respect to acquisition of a drug1 means the amount to be paid by the participant or beneficiary under the plan1 including any cost-sharing 7including any deductible1 copayment1 or coinsurance7 and1 as determined by the ,secretary1 any other expenditure4 4 7#b7 ,clerical amendment ,the table of sections for subchapter ,b of chapter #ajj of the ,internal ,revenue ,code of #aihf1 as amended by section #ajf1 is further amended by adding at the end the following new item3 ,sec4 #ihbg4 ,information on prescription drugs4 4 #djd4 ,implementation funding 7a7 ,in general ,for the purposes described in subsection 7b71 and in addition to amounts otherwise available for such purposes there are appropriated1 out of amounts in the ,treasury not otherwise appropriated1 to the ,secretary of ,labor #ce1jjj1jjj1 for fiscal year #bjbd1 to remain available through fiscal year #bjbi4 7b7 ,permitted purposes ,the purposes described in this subsection are limited to the following purposes1 insofar as such purposes are to carry out the provisions of1 including the amendments made by1 title ,i and ,,iv3 7#a7 ,preparing1 drafting1 and issuing proposed and final regulations or interim regulations4 7#b7 ,preparing1 drafting1 and issuing guidance and public information4 7#c7 ,preparing1 drafting1 and publishing reports4 7#d7 ,enforcement of such provisions4 7#e7 ,reporting1 collection1 and analysis of data4 7#f7 ,other administrative duties necessary for implementation of such provisions4 7c7 ,transparency of implementation funds ,the ,secretary of ,labor shall annually submit1 no later than ,september #ast of each year1 to the ,committees on ,education and ,workforce and on ,appropriations of the ,house of ,representatives and the ,committees on ,health1 ,education1 ,labor1 and ,pensions and on ,appropriations of the ,senate a report on funds expended pursuant to funds appropriated under this section4 ,passed the ,house of ,representatives ,december #aa1 #bjbc4;,clerk4