,i #aaith ,,congress #ast ,session ,h4 ,r4 #bfg ,,in ,,the ,,house ,,of ,,representatives ,january #i1 #bjbe,mr4 ,davidson introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce ,a ,,bill ,to amend the ,public ,health ,service ,act to provide for hospital and insurer price transparency4 #a4 ,short title ,this ,act may be cited as the ,health ,care ,prices ,revealed and ,information to ,consumers ,explained ,transparency ,act or the ,health ,care ,,price ,transparency ,act4 #b4 ,price transparency requirements 7a7 ,hospitals ,section #bgah7;e7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ah7;e77 is amended-- 7#a7 by striking ,each hospital and inserting the following3 7#a7 ,in general ,each hospital 2 7#b7 by inserting 1 in plain language without subscription and free of charge1 in a consumer-friendly1 machine-readable format1 after a list2 and 7#c7 by adding at the end the following3 8,each hospital shall include in its list of standard charges1 along with such additional information as the ,secretary may require with respect to such charges for purposes of promoting public awareness of hospital pricing in advance of receiving a hospital item or service1 as applicable1 the following3 7,a7 ,a description of each item or service provided by the hospital4 7,b7 ,the gross charge4 7,c7 ,any payer-specific negotiated charge clearly associated with the name of the third party payer and plan4 7,d7 ,the de-identified minimum negotiated charge4 7,e7 ,the de-identified maximum negotiated charge4 7,f7 ,the discounted cash price4 7,g7 ,any code used by the hospital for purposes of accounting or billing1 including ,current ,procedural ,terminology 7,,cpt7 code1 the ,healthcare ,common ,procedure ,coding ,system 7,,hcpcs7 code1 the ,diagnosis ,related ,group 7,,drg71 the ,national ,drug ,code 7,,ndc71 or other common payer identifier4 7#b7 ,delivery methods and use 7,a7 ,in general ,each hospital shall make public the standard charges described in paragraph 7#a7 for as many of the #gj ,centers for ,medicaid ,medicare ,services-specified shoppable services that are provided by the hospital1 and as many additional hospital-selected shoppable services as may be necessary for a combined total of at least #cjj shoppable services1 including the rate at which a hospital provides and bills for that shoppable service4 ,if a hospital does not provide #cjj shoppable services in accordance with the previous sentence1 the hospital shall make public the information specified under paragraph 7#a7 for as many shoppable services as it provides4 7,b7 ,determination by ,,cms ,a hospital shall be deemed by the ,centers for ,medicare ,medicaid ,services to meet the requirements of subparagraph 7,a7 if the hospital maintains an internet-based price estimator tool that meets the following requirements3 7i7 ,the tool provides estimates for as many of the #gj specified shoppable services that are provided by the hospital1 and as many additional hospital-selected shoppable services as may be necessary for a combined total of at least #cjj shoppable services4 7ii7 ,the tool allows health care consumers to1 at the time they use the tool1 obtain an estimate of the amount they will be obligated to pay the hospital for the shoppable service4 7iii7 ,the tool is prominently displayed on the hospital's website and easily accessible to the public1 without subscription1 fee1 or having to submit personal identifying information 7,,pii71 and searchable by service description1 billing code1 and payer4 7#c7 ,definitions ,notwithstanding any other provision of law1 for the purpose of paragraphs 7#a7 and 7#b73 7,a7 ,de-identified maximum negotiated charge ,the term de-identified maximum negotiated charge means the highest charge that a hospital has negotiated with all third party payers for an item or service4 7,b7 ,de-identified minimum negotiated charge ,the term de-identified minimum negotiated charge means the lowest charge that a hospital has negotiated with all third party payers for an item or service4 7,c7 ,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 item or service4 ,hospitals that do not offer self-pay discounts may display the hospital's undiscounted gross charges as found in the hospital chargemaster4 7,d7 ,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,e7 ,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,f7 ,shoppable service ,the term shoppable service means a service that can be scheduled by a health care consumer in advance4 7,g7 ,standard charges ,the term standard charges means the regular rate established by the hospital for an item or service1 including both individual items and services and service packages1 provided to a specific group of paying patients1 including the gross charge1 the payer-specific negotiated charge1 the discounted cash price1 the de-identified minimum negotiated charge1 the de-identified maximum negotiated charge1 and other rates determined by the ,secretary4 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 7#d7 ,enforcement ,in addition to any other enforcement actions or penalties that may apply under subsection 7b77#c7 or another provision of law1 a hospital that fails to provide the information required by this subsection and has not completed a corrective action plan to comply with the requirements of such subsection shall be subject to a civil monetary penalty of an amount not to exceed #cjj per day that the violation is ongoing as determined by the ,secretary4 ,such penalty shall be imposed and collected in the same manner as civil money penalties under subsection 7a7 of section #aabh;,a of the ,social ,security ,act are imposed and collected4 4 7b7 ,transparency in coverage ,section #acaa7;e77#c7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjca7;e77#c77 is amended-- 7#a7 in subparagraph 7,a7-- 7,a7 by redesignating clause 7ix7 as clause 7xii72 and 7,b7 by inserting after clause 7viii71 the following3 7ix7 ,in-network provider rates for covered items and services4 7x7 ,out-of-network allowed amounts and billed charges for covered items and services4 7xi7 ,negotiated rates and historical net prices for covered prescription drugs4 2 7#b7 in subparagraph 7,b7-- 7,a7 in the heading1 by striking use and inserting delivery methods and use2 7,b7 by inserting and subparagraph 7,c7 after subparagraph 7,a72 7,c7 by inserting 1 as applicable1 after ,english proficiency2 and 7,d7 by inserting after the second sentence1 the following3 8,the ,secretary shall establish standards for the methods and formats for disclosing information to individuals4 ,at a minimum1 these standards shall include the following3 7i7 ,an internet-based self-service tool to provide information to an individual in plain language1 without subscription and free of charge1 in a machine readable format1 through a self-service tool on an internet website that provides real-time responses based on cost-sharing information that is accurate at the time of the request that allows1 at a minimum1 users to-- 7,i7 search for cost-sharing information for a covered item or service provided by a specific in-network provider or by all in-network providers2 7,,ii7 search for an out-of-network allowed amount1 percentage of billed charges1 or other rate that provides a reasonably accurate estimate of the amount an insurer will pay for a covered item or service provided by out-of-network providers2 and 7,,iii7 refine and reorder search results based on geographic proximity of in-network providers1 and the amount of the individual's cost-sharing liability for the covered item or service1 to the extent the search for cost-sharing information for covered items or services returns multiple results4 7ii7 ,in paper form at the request of the individual that includes no fewer than #bj providers per request with respect to which cost-sharing information for covered items and services is provided1 and discloses the applicable provider per-request limit to the individual1 mailed to the individual not later than #b business days after receiving an individual's request4 2 7#c7 in subparagraph 7,c7-- 7,a7 in the first sentence-- 7i7 by striking ,the ,exchange and inserting the following3 7i7 ,in general ,the ,exchange 2 7ii7 by inserting or out-of-network provider after item or service by a participating provider2 and 7iii7 by inserting before the period the following3 8the following information3 7i7 ,an estimate of an individual's cost-sharing liability for a requested covered item or service furnished by a provider1 which shall reflect any cost-sharing reductions the individual would receive4 7ii7 ,a description of the accumulated amounts4 7iii7 ,the in-network rate1 including negotiated rates and underlying fee schedule rates4 7iv7 ,the out-of-network allowed amount or any other rate that provides a more accurate estimate of an amount an issuer will pay1 including the percent reimbursed by insurers to out-of-network providers1 for the requested covered item or service furnished by an out-of-network provider4 7v7 ,a list of the items and services included in bundled payment arrangements for which cost-sharing information is being disclosed4 7vi7 ,a notification that coverage of a specific item or service is subject to a prerequisite1 if applicable4 7vii7 ,a notice that includes the following information3 7,i7 ,a statement that out-of-network providers may bill individuals for the difference1 including the balance billing1 between a provider's billed charges and the sum of the amount collected from the insurer in the form of a copayment or coinsurance amount and the cost-sharing information4 7,,ii7 ,a statement that the actual charges for an individual's covered item or service may be different from an estimate of cost-sharing liability depending on the actual items or services the individual receives at the point of care4 7,,iii7 ,a statement that the estimate of cost-sharing liability for a covered item or service is not a guarantee that benefits will be provided for that item or service4 7,,iv7 ,a statement disclosing whether the plan counts copayment assistance and other third-party payments in the calculation of the individual's deductible and out-of-pocket maximum4 7,v7 ,for items and services that are recommended preventive services under section #bgac of the ,public ,health ,service ,act1 a statement that an in-network item or service may not be subject to cost-sharing if it is billed as a preventive service in the insurer cannot determine whether the request is for a preventive or non-preventive item or service4 7,,vi7 ,any additional information1 including other disclaimers1 that the insurer determines is appropriate1 provided the additional information does not conflict with the information required to be provided by this subsection4 2 7,b7 by striking the second sentence2 and 7,c7 by adding at the end the following3 7ii7 ,definitions ,notwithstanding any other provision of law1 for the purpose of this subparagraph and subparagraphs 7,a7 and 7,b73 7,i7 ,accumulated amounts ,the term accumulated amounts means the amount of financial responsibility an individual has incurred at the time a request for cost-sharing information is made1 with respect to a deductible or out-of-pocket limit1 including any expense that counts toward a deductible or out-of-pocket limit1 but exclude any expense that does not count toward a deductible or out-of-pocket limit4 ,to the extent an insurer imposes a cumulative treatment limitation on a particular covered item or service independent of individual medical necessity determinations1 the amount that has accrued toward the limit on the item or service4 7,,ii7 ,historical net price ,the term historical net price means the retrospective average amount an insurer paid for a prescription drug1 inclusive of any reasonably allocated rebates1 discounts1 chargebacks1 fees1 and any additional price concessions received by the insurer with respect to the prescription drug4 ,the allocation shall be determined by dollar value for non-product specific and product-specific rebates1 discounts1 chargebacks1 fees1 and other price concessions to the extent that the total amount of any such price concession is known to the insurer at the time of publication of the historical net price4 7,,iii7 ,negotiated rate ,the term negotiated rate means the amount a plan or issuer has contractually agreed to pay for a covered item or service1 whether directly or indirectly through a third party administrator or pharmacy benefit manager1 to an in-network provider1 including an in-network pharmacy or other prescription drug dispenser1 for covered items or services4 7,,iv7 ,out-of-network allowed amount ,the term out-of-network allowed amount means the maximum amount an insurer will pay for a covered item or service furnished by an out-of-network provider4 7,v7 ,out-of-network limit ,the term out-of-network limit means the maximum amount that an individual is required to pay during a coverage period for his or her share of the costs of covered items and services under his or her plan or coverage1 including for self-only and other than self-only coverage1 as applicable4 7,,vi7 ,underlying fee schedule rates ,the term underlying fee schedule rates means the rate for an item or service that a plan or issuer uses to determine a participant's1 beneficiary's1 or enrollee's cost-sharing liability from a particular provider or providers1 when the rate is different from the negotiated rate4 2 7#d7 in subparagraph 7,d71 by striking subparagraph 7,a7 and inserting subparagraphs 7,a71 7,b71 and 7,c72 and 7#e7 by adding at the end the following3 7,f7 ,application of paragraph ,in addition to qualified health plans 7and plans seeking certification as qualified health plans71 this paragraph 7as amended by the ,health ,care ,prices ,revealed and ,information to ,consumers ,explained ,transparency ,act7 shall apply to group health plans 7including self-insured and fully insured plans7 and health insurance coverage 7as such terms are defined in section #bgia of the ,public ,health ,service ,act74 4