,i #aaith ,,congress #b;d ,session ,h4 ,r4 #ifde ,,in ,,the ,,house ,,of ,,representatives ,july #ac1 #bjbf ,mr4 ,smith of ,missouri introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committees on ,ways and ,means1 and ,education and ,workforce1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to promote health care price transparency1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,health ,care ,price ,certainty for ,all ,americans ,act4 #b4 ,requiring certain facilities under the ,medicare program to disclose certain information relating to charges and prices 7a7 ,in general ,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;,d4 ,health care provider price transparency 7a7 ,hospitals 7#a7 ,in general ,beginning ,january #a1 #bjbg1 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 hospital-- 7i7 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 and update not less frequently than annually 7or at such greater frequency as may be specified by the ,secretary7-- 7,i7 all of the hospital's standard charges 7including the information described in subparagraph 7,b77 for each item and service furnished by such hospital2 7,,ii7 information-- 7aa7 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 7bb7 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 7ii7 post in a publicly accessible location of such hospital 7in a form and manner specified by the ,secretary7 the discounted cash price1 as applicable1 expressed as a dollar amount1 for each ,centers for ,medicare ,medicaid ,services-specified shoppable service that is furnished by the hospital when provided in1 as applicable1 the inpatient setting and outpatient department setting 7or1 in the case no discounted cash price is available for such service1 the median cash price charged by the hospital to self-pay individuals for such service when provided in such settings for the previous three years1 expressed as a dollar amount72 and 7iii7 submit to the ,secretary 7in a form and manner specified by the ,secretary and on an annual basis7 an attestation1 signed by the chief executive officer1 chief financial officer1 or other comparable official 7as specified by the ,secretary7 of such hospital1 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 7as specified by the ,secretary7 of each item or service1 accompanied by1 as applicable1 commonly recognized billing code sets1 including the ,healthcare ,common ,procedure ,coding ,system code1 the diagnosis-related group1 the national drug code1 or other applicable identifier determined appropriate by the ,secretary4 7ii7 ,for each such item or service when provided in1 as applicable1 the inpatient and outpatient department settings-- 7,i7 the gross charge1 as applicable1 expressed as a dollar amount2 7,,ii7 each payer-specific negotiated charge in effect between such hospital and a third party payer1 expressed as a dollar amount2 7,,iii7 the deidentified maximum and minimum payer-specific negotiated charges in effect between such hospital and any third party payer2 and 7,,iv7 the discounted cash price1 as applicable1 expressed as a dollar amount 7or1 in the case no discounted cash price is available for such item or service1 the median cash price charged by the hospital 7not including charity care7 to self-pay individuals for such item or service when provided in such settings for the previous three years1 expressed as a dollar amount74 7iii7 ,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 prices4 7iv7 ,any other additional information the ,secretary may require 7in consultation with stakeholders7 for the purpose of improving the accuracy of1 or enabling consumers to easily understand and compare1 standard charges and prices for an item or service 7which may include1 in the case that charges described in clause 7iii7 for an item or service are unable to be expressed as a dollar amount1 such information relating to past allowed charges for such item or service as may be specified by the ,secretary71 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 #bjbh1 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,a77i77,i7 and a standard1 uniform method and format for such hospitals to use in compiling and making public prices pursuant to subparagraph 7,a77i77,,ii74 ,such methods and formats-- 7i7 shall1 in the case of such method and format for making public-- 7,i7 standard charges pursuant to subparagraph 7,a77i77,i71 ensure that such charges are made available in a machine-readable format 7or a successor technology specified by the ,secretary72 and 7,,ii7 prices pursuant to subparagraph 7,a77i77,,ii71 ensure that such prices are made available in a consumer-friendly format 7as 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,d7 ,deemed compliance with shoppable services requirement for hospitals with a price estimator tool 7i7 ,in general ,before the effective date of regulations implementing the provisions of sections #bgii;,a-#a7;f7 and #bgii;,b-#f of the ,public ,health ,service ,act 7relating to advanced explanations of benefits71 including regulations on establishing data transfer standards to effectuate such provisions1 a specified hospital shall be deemed to have compiled and made public information described in subparagraph 7,a77i77,,ii7 7relating to shoppable services7 in accordance with a method and format specified by the ,secretary under subparagraph 7,c7 if such hospital maintains a price estimator tool described in clause 7ii74 7ii7 ,price estimator tool described ,for purposes of clause 7i71 a price estimator tool described in this subparagraph is1 with respect to a specified hospital1 a tool that meets the following requirements3 7,i7 ,such tool allows an individual to immediately obtain a price estimate 7taking into account whether such individual is covered under any plan1 coverage1 or program described in subclause 7,,iv77cc77 and the discounted cash price charged by a specified hospital for each ,centers for ,medicare ,medicaid ,services-specified shoppable service that is furnished by such hospital1 and for each additional shoppable service as such hospital may select1 such that price estimates are available through such tool for at least #cjj shoppable services 7or for all such services1 if such hospital furnishes fewer than #cjj shoppable services74 7,,ii7 ,such tool allows an individual to obtain such an estimate by billing code and by service description4 7,,iii7 ,such tool is prominently displayed on the public internet website of such hospital4 7,,iv7 ,such tool does not require an individual seeking such an estimate to create an account or otherwise input personal information1 except that such tool may require that such individual provide information specified by the ,secretary1 which may include the following3 7aa7 ,the name of such individual4 7bb7 ,the date of birth of such individual4 7cc7 ,in the case such individual is covered under a group health plan1 group or individual health insurance coverage1 a ,federal health care program1 or the program established under chapter #hi of title #e1 ,united ,states ,code1 an identifying number assigned by such plan1 coverage1 or program to such individual4 7dd7 ,in the case of an individual described in item 7cc71 an indication as to whether such individual is the primary insured individual under such plan1 coverage1 or program 7and1 if such individual is not the primary insured individual1 a description of the individual's relationship to such primary insured individual74 7ee7 ,any other information specified by the ,secretary4 7,v7 ,such tool contains a statement confirming the accuracy and completeness of information presented through such tool as of the date such request is made4 7,,vi7 ,such tool meets any other requirement specified by the ,secretary4 7#c7 ,monitoring compliance ,the ,secretary shall establish processes to monitor and assess specified hospitals' compliance with this subsection4 ,such processes shall ensure that each specified hospital's compliance with this subsection is reviewed not less frequently than once every #c years and include processes relating to the following3 7,a7 ,the evaluation and analysis of complaints made by individuals or other entities relating to such hospitals' compliance with this subsection4 7,b7 ,the use of audits to ensure such hospitals' compliance with this subsection4 7,c7 ,the obtaining of additional information from such hospitals to determine such hospitals' compliance with this subsection 7as determined appropriate by the ,secretary74 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 7to be submitted not later than #de days after such request is made7 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 #fj 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 7to be submitted not later than #de days after such request is made7 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 ,federal 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 #ij days after such request is made 7or1 if such hospital has submitted such a corrective action plan not later than #de days after the date such request was made1 by the date that is #ij days after the date of the submission of such corrective action plan71 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 #cdb per day2 7,,ii7 in the case of a specified hospital with more than #cj beds but fewer than #eej beds1 #aa per bed per day2 and 7,,iii7 in the case of a specified hospital with #eej beds or more1 #f1bgg per day4 7ii7 ,increase authority ,in applying this subparagraph with respect to failures to comply occurring in #bjbi 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 subclause 7,i7 or 7,,iii7 of clause 7i72 7,,ii7 the limitations on the per bed per day amount of any penalty applicable under clause 7i77,,ii72 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 for two or more #f-month periods during any #c-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 area 7as defined by the ,federal ,office of ,rural ,health ,policy for the purpose of rural health grant programs administered by such ,office7 or an underserved area if the ,secretary determines 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 ,hardship exemption ,notwithstanding any limit on the waiver or reduction of a penalty under clause 7iv71 the ,secretary may waive any penalty with respect to a specified hospital on a case-by-case basis if the ,secretary determines that a circumstance exists interfering with such hospital's ability to comply with the provisions of this subsection 7such as a natural disaster 7as defined in section #fjb7;a7 of the ,robert ,t4 ,stafford ,disaster ,relief and ,emergency ,assistance ,act71 a public health emergency1 or other unique or unexpected event74 7vi7 ,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 7vii7 ,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 7,c7 ,publication of hospital price transparency information ,beginning on ,january #a1 #bjbh1 the ,secretary shall make publicly available on the 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 7if practicable7 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 reduction1 but only to the extent that such rationale does not make public commercially sensitive information2 and 7vii7 any other information as determined by the ,secretary4 7b7 ,clinical diagnostic laboratory services 7#a7 ,in general ,beginning ,january #a1 #bjbh1 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 available1 in accordance with a method and format established by the ,secretary under paragraph 7#c71 the information described in paragraph 7#b7 with respect to each such specified clinical diagnostic laboratory test that such laboratory so furnishes2 7,b7 update such information not less frequently than annually 7or at such greater frequency as the ,secretary may specify72 7,c7 submit to the ,secretary on an annual basis an attestation1 signed by the chief executive officer1 chief financial officer1 or other comparable official 7as specified by the ,secretary7 of such laboratory1 that all such information is complete and accurate2 and 7,d7 post in a publicly accessible location of such laboratory 7in a form and manner specified by the ,secretary7 the discounted cash price1 as applicable1 expressed as a dollar amount1 for each ,centers for ,medicare ,medicaid ,services-specified shoppable service that is furnished by the laboratory 7or1 in the case no discounted cash price is available for such service1 the median cash price charged by the laboratory to self-pay individuals for such service for the previous three years1 expressed as a dollar amount74 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 discounted cash price for such test 7or1 if no such price exists1 the gross charge for such test74 7#c7 ,uniform method and format ,not later than ,january #a1 #bjbh1 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 subsection 7a77#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 charge for a specified clinical diagnostic laboratory test furnished by an applicable laboratory made publicly available in accordance with paragraph 7#a7 shall include the price or charge 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 ,monitoring compliance ,the ,secretary shall1 through notice and comment rulemaking1 establish a process to monitor compliance with this subsection4 7#f7 ,enforcement 7,a7 ,in general ,in the case that the ,secretary determines that an applicable laboratory is not in compliance with the requirements of paragraph 7#a7-- 7i7 not later than #cj days after such determination1 the ,secretary shall notify such laboratory of such determination 7which may include1 as determined appropriate by the ,secretary1 a request for a corrective action plan 7to be submitted not later than #de days after such request is made772 and 7ii7 in the case of a laboratory that does not receive a request for a corrective action plan as part of a notification under clause 7i7-- 7,i7 the ,secretary shall1 not later than #ij days after such notification is sent1 determine whether such laboratory is in compliance with such requirements2 and 7,,ii7 if the ,secretary determines under subclause 7,i7 that such laboratory is not in compliance with such requirements1 the ,secretary shall either-- 7aa7 submit to such laboratory a request for a corrective action plan 7to be submitted not later than #de days after such request is made7 to comply with such requirements2 or 7bb7 if the ,secretary determines that such laboratory 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 ,an applicable laboratory 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 paragraph 7#a7 by the date that is #ij days after such request is made1 and an applicable laboratory 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 in an amount not to exceed #cjj 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 7,c7 ,increase authority ,in applying this paragraph with respect to failures to comply occurring in #bjbi or a subsequent year1 the ,secretary may through notice and comment rulemaking increase the per day limitation on civil monetary penalties under subparagraph 7,b74 7,d7 ,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,e7 ,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 an applicable laboratory under this paragraph if the ,secretary determines that imposition of such penalty would result in an immediate threat to access to care for individuals in the service area of such laboratory4 7ii7 ,limitation ,the ,secretary may not elect to waive or reduce a penalty under clause 7i7 with respect to an applicable laboratory more than #c times in a #aj year period4 7,f7 ,hardship exemption ,notwithstanding any limit on the waiver or reduction of a penalty under subparagraph 7,e71 the ,secretary may waive any penalty with respect to an applicable laboratory on a case-by-case basis if the ,secretary determines that a circumstance exists interfering with such laboratory's ability to comply with the provisions of this subsection 7such as a natural disaster 7as defined in section #fjb7;a7 of the ,robert ,t4 ,stafford ,disaster ,relief and ,emergency ,assistance ,act71 a public health emergency1 or other unique or unexpected event74 7#g7 ,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#h7 ,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-- 7i7 a specified hospital pursuant to subsection 7a72 or 7ii7 an ambulatory surgical center pursuant to subsection 7d74 7,b7 ,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 subsection 7a77#b77;,a77i77,,ii771 other than an advanced diagnostic laboratory test 7as defined in section #ahcd;,a7d77#e774 7c7 ,imaging services 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 specified hospital pursuant to subsection 7a7 or an ambulatory surgical center pursuant to subsection 7d71 shall-- 7,a7 make publicly available1 in accordance with a method and format established by the ,secretary under paragraph 7#c71 the information described in paragraph 7#b7 with respect to each such service that such provider of services or supplier furnishes2 7,b7 updated such information not less frequently than annually 7or at such greater frequency as the ,secretary may specify72 7,c7 submit to the ,secretary on an annual basis an attestation1 signed by the chief executive officer1 chief financial officer1 or other comparable official 7as specified by the ,secretary7 of such provider or supplier1 that all such information is complete and accurate2 and 7,d7 post in a publicly accessible location of such provider or supplier 7in a form and manner specified by the ,secretary7 the discounted cash price1 as applicable1 expressed as a dollar amount1 for each ,centers for ,medicare ,medicaid ,services-specified shoppable service that is furnished by the provider or supplier 7or1 in the case no discounted cash price is available for such service1 the median cash price charged by the provider or supplier to self-pay individuals for such service for the previous three years1 expressed as a dollar amount74 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 discounted cash price for such service 7or1 if no such price exists1 the gross charge for such service74 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 subsection 7a77#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 rulemaking1 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 the requirements of paragraph 7#a7-- 7i7 not later than #cj days after such determination1 the ,secretary shall notify such provider or supplier of such determination 7which may include1 as determined appropriate by the ,secretary1 a request for a corrective action plan 7to be submitted not later than #de days after such request is made772 and 7ii7 in the case of a provider of services or supplier that does not receive a request for a corrective action plan as part of a notification under clause 7i7-- 7,i7 the ,secretary shall1 not later than #ij days after such notification is sent1 determine whether such provider or supplier is in compliance with such requirements2 and 7,,ii7 if the ,secretary determines under subclause 7,i7 that such provider or supplier is not in compliance with such requirements1 the ,secretary shall either-- 7aa7 submit to such provider or supplier a request for a corrective action plan 7to be submitted not later than #de days after such request is made7 to comply with such requirements2 or 7bb7 if the ,secretary determines that such provider or supplier 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 ,a provider of services or supplier 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 paragraph 7#a7 by the date that is #ij days after such request is made1 and a provider of services or supplier 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 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 not complying with such requirements7 during which such failure was ongoing4 7,c7 ,increase authority ,in applying this paragraph with respect to failures to comply 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,b74 7,d7 ,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,e7 ,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 paragraph if the ,secretary determines 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 times in a #aj year period4 7,f7 ,hardship exemption ,notwithstanding any limit on the waiver or reduction of a penalty under subpargraph 7,e71 the ,secretary may waive any penalty with respect to a provider of services or supplier on a case-by-case basis if the ,secretary determines that a circumstance exists interfering with such provider's or supplier's ability to comply with the provisions of this subsection 7such as a natural disaster 7as defined in section #fjb7;a7 of the ,robert ,t4 ,stafford ,disaster ,relief and ,emergency ,assistance ,act71 a public health emergency1 or other unique or unexpected event74 7,g7 ,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 ,definition ,in this subsection1 the term specified imaging service means an imaging service that is included on the list of ,centers for ,medicare ,medicaid ,services-specified shoppable services 7as described in subsection 7a77i77,,ii774 7d7 ,ambulatory surgical centers 7#a7 ,in general ,beginning ,january #a1 #bjbh1 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 center-- 7i7 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 and update not less frequently than annually 7or at such greater frequency as may be specified by the ,secretary7-- 7,i7 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 7,,ii7 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 7as specified by the ,secretary7 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 7,,iii7 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 furnished2 7ii7 submit to the ,secretary on an annual basis an attestation1 signed by the chief executive officer1 chief financial officer1 or other comparable official 7as specified by the ,secretary7 of such center1 that all information made public pursuant to this subparagraph is complete and accurate2 and 7iii7 post in a publicly accessible location of such center 7in a form and manner specified by the ,secretary7 the discounted cash price1 as applicable1 expressed as a dollar amount1 for each ,centers for ,medicare ,medicaid ,services-specified shoppable service that is furnished by the center 7or1 in the case no discounted cash price is available for such service1 the median cash price charged by the center to self-pay individuals for such service for the previous three years1 expressed as a dollar amount74 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 an ambulatory surgical center1 the following3 7i7 ,a plain language description 7as specified by the ,secretary7 of each item or service1 accompanied by1 as applicable1 commonly recognized billing code sets1 including the ,healthcare ,common ,procedure ,coding ,system code1 the national drug code1 or other applicable identifier determined appropriate by the ,secretary4 7ii7 ,for each such item or service-- 7,i7 the gross charge1 as applicable1 expressed as a dollar amount2 7,,ii7 each payer-specific negotiated charge in effect between such center and a third party payer1 expressed as a dollar amount2 7,,iii7 the deidentified maximum and minimum payer-specific negotiated charges in effect between such center and any third party payer2 and 7,,iv7 the discounted cash price1 as applicable1 expressed as a dollar amount 7or1 in the case no discounted cash price is available for an item or service1 the median cash price charged to self-pay individuals 7not including charity care7 for such item or service for the previous three years1 expressed as a dollar amount74 7iii7 ,any other additional information the ,secretary may require 7in consultation with stakeholders7 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 #bjbh1 the ,secretary shall establish a standard1 uniform method and format for ambulatory surgical centers to use in making public standard charges pursuant to subparagraph 7,a77i7 and a standard1 uniform method and format for such centers to use in making public prices pursuant to subparagraph 7,a77ii74 ,any such method and format-- 7i7 shall1 in the case of-- 7,i7 standard charges made public by an ambulatory surgical center under subparagraph 7,a77i71 ensure that such charges are made available in a machine-readable format 7or successor technology72 and 7,,ii7 prices made public by an ambulatory surgical center under subparagraph 7,a77ii71 ensure that such prices are made available in a consumer-friendly format 7as specified by the ,secretary72 7ii7 may be similar to any template made available by the ,centers for ,medicare ,medicaid ,services 7as described in subsection 7a77#b77;,c77ii772 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,d7 ,deemed compliance with shoppable services requirement for centers with a price estimator tool 7i7 ,in general ,before the effective date of regulations implementing the provisions of sections #bgii;,a-#a7;f7 and #bgii;,b-#f of the ,public ,health ,service ,act 7relating to advanced explanations of benefits71 including regulations on establishing data transfer standards to effectuate such provisions1 a specified hospital shall be deemed to have compiled and made public information described in subparagraph 7,a77i77,,ii7 7relating to shoppable services7 in accordance with a method and format specified by the ,secretary under subparagraph 7,c7 if such hospital maintains a price estimator tool described in clause 7ii74 7ii7 ,price estimator tool described ,for purposes of clause 7i71 a price estimator tool described in this subparagraph is1 with respect to an ambulatory surgical center1 a tool that meets the following requirements3 7,i7 ,such tool allows an individual to immediately obtain a price estimate 7taking into account whether such individual is covered under any plan1 coverage1 or program described in subclause 7,,iv77cc77 and the discounted cash price charged by an ambulatory surgical center for each ,centers for ,medicare ,medicaid ,services-specified shoppable service that is furnished by such center1 and for each additional shoppable service as such center may select1 such that price estimates are available through such tool for at least #cjj shoppable services 7or for all such services1 if such hospital furnishes fewer than #cjj shoppable services74 7,,ii7 ,such tool allows an individual to obtain such an estimate by billing code and by service description4 7,,iii7 ,such tool is prominently displayed on the public internet website of such center4 7,,iv7 ,such tool does not require an individual seeking such an estimate to create an account or otherwise input personal information1 except that such tool may require that such individual provide information specified by the ,secretary1 which may include the following3 7aa7 ,the name of such individual4 7bb7 ,the date of birth of such individual4 7cc7 ,in the case such individual is covered under a group health plan1 group or individual health insurance coverage1 a ,federal health care program1 or the program established under chapter #hi of title #e1 ,united ,states ,code1 an identifying number assigned by such plan1 coverage1 or program to such individual4 7dd7 ,in the case of an individual described in item 7cc71 an indication as to whether such individual is the primary insured individual under such plan1 coverage1 or program 7and1 if such individual is not the primary insured individual1 a description of the individual's relationship to such primary insured individual74 7ee7 ,any other information specified by the ,secretary4 7,v7 ,such tool contains a statement confirming the accuracy and completeness of information presented through such tool as of the date such request is made4 7,,vi7 ,such tool meets any other requirement specified by the ,secretary4 7#c7 ,monitoring compliance ,the ,secretary shall establish processes to monitor and assess ambulatory surgical centers' compliance with this subsection4 ,such processes shall include processes relating to the following3 7,a7 ,the evaluation and analysis of complaints made by individuals or other entities relating to such centers' compliance with this subsection4 7,b7 ,the use of audits to ensure such centers' compliance with this subsection4 7,c7 ,the obtaining of additional information from such centers to determine such centers' compliance with this subsection 7as determined appropriate by the ,secretary74 7#d7 ,enforcement 7,a7 ,in general ,in the case that the ,secretary determines that an ambulatory surgical center is not in compliance with the requirements of paragraph 7#a7-- 7i7 not later than #cj days after such determination1 the ,secretary shall notify such center of such determination 7which may include1 as determined appropriate by the ,secretary1 a request for a corrective action plan 7to be submitted not later than #de days after such request is made772 and 7ii7 in the case of an ambulatory surgical center that does not receive a request for a corrective action plan as part of a notification under clause 7i7-- 7,i7 the ,secretary shall1 not later than #ij days after such notification is sent1 determine whether such center is in compliance with such requirements2 and 7,,ii7 if the ,secretary determines under subclause 7,i7 that such center is not in compliance with such requirements1 the ,secretary shall either-- 7aa7 submit to such center a request for a corrective action plan 7to be submitted not later than #de days after such request is made7 to comply with such requirements2 or 7bb7 if the ,secretary determines that such center 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 ,an ambulatory surgical center 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 paragraph 7#a7 by the date that is #ij days after such request is made1 and an ambulatory surgical center 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 in an amount not to exceed #cjj for each day 7beginning with the day on which the ,secretary first determined that such center was not complying with such requirements7 during which such failure was ongoing4 7ii7 ,increase authority ,in applying this subparagraph with respect to failures to comply occurring in #bjbi or a subsequent year1 the ,secretary may through notice and comment rulemaking increase the limitation on the per day amount of any penalty 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 7v7 ,hardship exemption ,notwithstanding any limit on the waiver or reduction of a penalty under clause 7iv71 the ,secretary may waive any penalty with respect to an ambulatory surgical center on a case-by-case basis if the ,secretary determines that a circumstance exists interfering with such center's ability to comply with the provisions of this subsection 7such as a natural disaster 7as defined in section #fjb7;a7 of the ,robert ,t4 ,stafford ,disaster ,relief and ,emergency ,assistance ,act71 a public health emergency1 or other unique or unexpected event74 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 ambulatory surgical centers requesting such assistance4 7e7 ,ensuring accessibility through implementation ,in implementing this section1 the ,secretary shall through rulemaking ensure that a provider of services or supplier making public charges and prices pursuant to this section 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 provision of interpretation services or the provision of translations of charges and information4 7f7 ,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 ,gross charge ,the term gross charge means the charge for an individual item or service that is reflected on a specified hospital's chargemaster or provider of service or supplier's1 as applicable1 chargemaster 7or similar list of prices71 absent any discounts4 7#c7 ,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#d7 ,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#e7 ,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#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 an item or service4 4 7b7 ,conforming amendment ,section #bgah7;e7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ah7;e77 is amended by adding at the end the following new sentence3 ,the preceding provisions of this subsection shall not apply beginning on ,january #a1 #bjbh44 #c4 ,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-- 7i7 in the header1 by striking ,maintenance of price comparison tool and inserting ,transparency in coverage2 7ii7 by striking ,a group health plan and inserting the following3 7a7 ,maintenance of price comparison tool for plan years before #bjbi 7#a7 ,in general ,a group health plan 2 7iii7 in subsection 7a71 as inserted by clause 7ii71 by adding at the end the following new paragraph3 7#b7 ,sunset ,paragraph 7#a7 shall not apply with respect to plan years beginning on or after ,january #a1 #bjbi4 2 and 7iv7 by adding at the end the following new subsections3 7b7 ,cost-sharing transparency 7#a7 ,in general ,for plan years beginning on or after ,january #a1 #bjbi1 a group health plan shall provide a participant or beneficiary1 in a timely manner upon request of the participant or beneficiary1 information on 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 provider4 ,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 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 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 a participant and such participant's 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 financial incentives 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,h7 ,other information determined appropriate by the ,secretary4 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 is made available in plain language at no cost2 7,c7 provides for real-time responses to requests described in paragraph 7#a72 7,d7 is updated in a manner such that information provided through such tool is timely and accurate at the time such request is made2 7,e7 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 7ii7 all providers that are participating providers with respect to such item or service2 or 7iii7 nonspecific providers located in a relevant geographic region that are not participating providers with respect to such item or service2 7,f7 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,g7 meets any other requirement determined appropriate by the ,secretary1 including requirements to ensure the accessibility and usability of information provided through such tool4 7c7 ,rate and payment information 7#a7 ,in general ,for plan years beginning on or after ,january #a1 #bjbi1 each group health plan 7other than a grandfathered health plan 7as defined in section #abea7;e7 of the ,patient ,protection and ,affordable ,care ,act7 or a church plan 7as defined in section #dad7;e777 shall 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 plan-- 7i7 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 service 7other than1 in the case that such plan provides benefits for such item or service only when furnished by a specific type of provider1 such a participating provider who is not such type of provider 7referred to in this subparagraph as an excluded provider772 and 7ii7 with respect to each such participating provider 7other than a provider that is an excluded provider with respect to such item or service71 an indication of whether1 during the #a-year period beginning #ah months before the date such information is made public1 such provider submitted a claim for such item or service to such plan for which payment was made 7in whole or in part7 under such plan4 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 7ii7 the average amount paid by such plan 7accounting for1 in a manner determined appropriate by the ,secretary1 rebates1 discounts1 price concessions1 and any other remuneration specified by the ,secretary7 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 unless fewer than #bj claims for such drug were submitted to such plan during such period2 and 7iii7 in the case such drug is an applicable spread price drug dispensed by a pharmacy-- 7,i7 a specification that such drug is such an applicable spread price drug2 and 7,,ii7 for each pharmacy that has a contractual relationship for dispensing such drug under such plan1 a specification of the difference 7if any7 between the specified payment amount for such drug so dispensed by such pharmacy and the specified reimbursement amount for such drug so dispensed by such pharmacy4 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 #f-month period beginning #i months before the date such information is made public by a provider that was not a participating provider with respect to such item or service1 broken down by each such provider1 other than such an amount with respect to an item or service for which1 during such period1 fewer than #aa claims were made under such plan4 ,in determining the number of claims made under such plan with respect to an item or service during such period for purposes of the preceding sentence1 such number shall be deemed to include all claims for such item or service made during such period under all group health plans offered in the same insurance market 7specified in subclause 7,i71 7,,ii71 7,,iii71 of section #ihaf7;a77#c77;,e77iv77 by the sponsor of the plan at issue4 ,in the case that a specific dollar amount for an in-network rate required to be made available pursuant to this subsection with respect to an item or service cannot be determined prospectively on the basis that such rate is determined as a percentage of the billed charges for such item or service1 such percentage and the median amount recognized by such plan as payment for such item or service with respect to claims for such item or service submitted by participating providers during the period described in subparagraph 7,a77ii7 shall be reported by such plan in lieu of such rate4 ,such plan shall identify that such median amount represents an estimate of such in-network rate for such item or service4 7#c7 ,manner of publication 7,a7 ,in general ,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 as applicable1 such as application programming 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 7which may be so specified through subregulatory guidance71 including requirements relating to whether such information should be so made available on the plan or coverage level1 with respect to individual provider networks1 or aggregated in such manner as specified by the ,secretary4 ,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 credentials or undertake other steps as may be specified by the ,secretary4 7,b7 ,timing ,rate and payment information described in paragraph 7#b7 shall be made public on a quarterly basis4 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 #bjbi1 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 or capitated rate-- 7i7 a description of the formulae1 pricing methodologies1 or other information used to calculate the payment rate for such rate2 and 7ii7 a list of the items and services included in such rate4 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 7d7 ,attestation ,a group health plan shall annually submit to the ,secretary an attestation1 signed by the chief executive officer1 chief financial officer1 or other comparable official 7as specified by the ,secretary7 of such plan1 of such plan's compliance with the provisions of this section and that information made available under this section is true1 accurate1 and complete4 ,such attestation shall1 except in the case of a grandfathered health plan 7as defined in section #abea7;e7 of the ,patient ,protection and ,affordable ,care ,act7 or a church plan 7as defined in section #dad7;e771 include a link to the website 7or other successor technology7 where rate and payment information required to be made public under subsection 7c7 may be accessed4 7e7 ,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 7b71 and rate and payment information made public under subsection 7c71 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 7f7 ,definitions ,in this section3 7#a7 ,applicable spread price drug ,the term applicable spread price drug means1 with respect to a group health plan1 a drug for which benefits are available under such plan and with respect to which1 at the time rate and payment information is made public by such plan under subsection 7c7-- 7,a7 a contract is in effect between an entity providing pharmacy benefit management services on behalf of such plan and a pharmacy for the dispensing of such drug under such plan2 and 7,b7 the specified payment amount for such drug so dispensed is less than the specified reimbursement amount for such drug so dispensed4 7#b7 ,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 7#c7 ,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 7as defined in paragraph 7#d77 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 for furnishing such item or service under the plan4 7#d7 ,provider ,the term provider includes a health care facility and a pharmacy4 7#e7 ,specified payment amount ,the term specified payment amount means1 with respect to a drug to be dispensed by a pharmacy to a participant or beneficiary of a group health plan where such pharmacy has in effect a contract with an entity providing pharmacy benefit management services on behalf of such plan for the dispensing of such drug under such plan1 the amount that such entity has agreed to pay such pharmacy for the ingredient costs and any applicable dispensing fee for such drug 7or the amount that such entity has agreed to pay such pharmacy for such drug under any other compensation structure specified by the ,secretary7 under such contract1 taking into account any cost sharing requirement applicable to such drug and participant or beneficiary4 7#f7 ,specified reimbursement amount ,the term specified reimbursement amount means1 with respect to a drug to be dispensed by a pharmacy to a participant or beneficiary of a group health plan where such pharmacy has in effect a contract with an entity providing pharmacy benefit management services on behalf of such plan for the dispensing of such drug under such plan1 the amount that such plan has agreed to pay to such entity for the ingredient costs and any applicable dispensing fee for such drug 7or the amount that such plan has agreed to pay such entity for such drug under any other compensation structure specified by the ,secretary71 taking into account any cost sharing requirement applicable to such drug and participant or beneficiary4 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-- 7,a7 in the header1 by striking ,maintenance of price comparison tool and inserting ,transparency in coverage2 7,b7 by striking ,a group health plan and inserting the following3 7a7 ,maintenance of price comparison tool for plan years before #bjbi 7#a7 ,in general ,a group health plan 2 7,c7 in subsection 7a71 as inserted by subparagraph 7,b71 by adding at the end the following new paragraph3 7#b7 ,sunset ,paragraph 7#a7 shall not apply with respect to plan years beginning on or after ,january #a1 #bjbi4 2 and 7,d7 by adding at the end the following new subsections3 7b7 ,cost-sharing transparency 7#a7 ,in general ,for plan years beginning on or after ,january #a1 #bjbi1 a group health plan and a health insurance issuer offering group or individual health insurance coverage shall provide a participant1 beneficiary1 or enrollee1 in a timely manner upon request of the participant1 beneficiary1 or enrollee1 information on the amount of cost-sharing 7including deductibles1 copayments1 and coinsurance7 under the participant1 beneficiary1 or enrollee's plan or coverage that the participant1 beneficiary1 or enrollee would be responsible for paying with respect to the furnishing of a specific item or service by a provider4 ,at a minimum1 such information shall include the information specified in paragraph 7#b7 and shall be made available to such participant1 beneficiary1 or enrollee through a self-service tool that meets the requirements of paragraph 7#c7 or1 at the option of such participant1 beneficiary1 or enrollee1 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 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 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 financial incentives 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,h7 ,other information determined appropriate by the ,secretary4 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 is made available in plain language at no cost2 7,c7 provides for real-time responses to requests described in paragraph 7#a72 7,d7 is updated in a manner such that information provided through such tool is timely and accurate at the time such request is made2 7,e7 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 7ii7 all providers that are participating providers with respect to such item or service2 or 7iii7 nonspecific providers located in a relevant geographic region that are not participating providers with respect to such item or service2 7,f7 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,g7 meets any other requirement determined appropriate by the ,secretary1 including requirements to ensure the accessibility and usability of information provided through such tool4 7c7 ,rate and payment information 7#a7 ,in general ,for plan years beginning on or after ,january #a1 #bjbi1 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 ,act7 and other than such an issuer offering group health insurance coverage in connection with a church plan 7as defined in section #dad7;e7 of the ,internal ,revenue ,code of #aihf77 shall 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 coverage-- 7i7 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 service 7other than1 in the case that such plan or coverage provides benefits for such item or service only when furnished by a specific type of provider1 such a participating provider who is not such type of provider 7referred to in this subparagraph as an excluded provider772 and 7ii7 with respect to each such participating provider 7other than a provider that is an excluded provider with respect to such item or service71 an indication of whether1 during the #a-year period beginning #ah months before the date such information is made public1 such provider submitted a claim for such item or service to such plan or coverage for which payment was made 7in whole or in part7 under such plan or coverage4 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 7ii7 the average amount paid by such plan or coverage 7accounting for1 in a manner determined appropriate by the ,secretary1 rebates1 discounts1 price concessions1 and any other remuneration specified by the ,secretary7 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 unless fewer than #bj claims for such drug were submitted to such plan or coverage during such period2 and 7iii7 in the case such drug is an applicable spread price drug dispensed by a pharmacy-- 7,i7 a specification that such drug is such an applicable spread price drug2 and 7,,ii7 for each pharmacy that has a contractual relationship for dispensing such drug under such plan or coverage1 a specification of the difference 7if any7 between the specified payment amount for such drug so dispensed by such pharmacy and the specified reimbursement amount for such drug so dispensed by such pharmacy4 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 plan or coverage1 for each such item or service furnished during the #f-month period beginning #i months before the date such information is made public by a provider that was not a participating provider with respect to such item or service1 broken down by each such provider1 other than such an amount with respect to an item or service for which1 during such period1 fewer than #aa claims were made under such plan or coverage4 ,in determining the number of claims made under such plan or coverage with respect to an item or service during such period for purposes of the preceding sentence1 such number shall be deemed to include all claims for such item or service made during such period under all group health plans and health insurance coverage offered in the same insurance market 7specified in subclause 7,i71 7,,ii71 7,,iii71 or 7,,iv7 of section #bgii;,a-#a7;a77#c77;,e77iv77 by the sponsor or issuer 7as applicable7 of the plan or coverage at issue4 ,in the case that a specific dollar amount for an in-network rate required to be made available pursuant to this subsection with respect to an item or service cannot be determined prospectively on the basis that such rate is determined as a percentage of the billed charges for such item or service1 such percentage and the median amount recognized by such plan or coverage as payment for such item or service with respect to claims for such item or service submitted by participating providers during the period described in subparagraph 7,a77ii7 shall be reported by such plan in lieu of such rate4 ,such plan or coverage shall identify that such median amount represents an estimate of such in-network rate for such item or service4 7#c7 ,manner of publication 7,a7 ,in general ,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 as applicable1 such as application programming 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 7which may be so specified through subregulatory guidance71 including requirements relating to whether such information should be so made available on the plan or coverage level1 with respect to individual provider networks1 or aggregated in such manner as specified by the ,secretary4 ,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,b7 ,timing ,rate and payment information described in paragraph 7#b7 shall be made public on a quarterly basis4 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 #bjbi1 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 or capitated rate-- 7i7 a description of the formulae1 pricing methodologies1 or other information used to calculate the payment rate for such rate2 and 7ii7 a list of the items and services included in such rate4 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 7d7 ,attestation ,each group health plan and health insurance issuer offering group or individual health insurance coverage shall annually submit to the ,secretary an attestation1 signed by the chief executive officer1 chief financial officer1 or other comparable official 7as specified by the ,secretary7 of such plan or issuer1 of such plan's or coverage's compliance with the provisions of this section and that information made available under this section is true1 accurate1 and complete4 ,such attestation shall1 except in the case of a grandfathered health plan 7as defined in section #abea7;e7 of the ,patient ,protection and ,affordable ,care ,act7 or in the case of such an issuer offering group health insurance coverage in connection with a church plan 7as defined in section #dad7;e7 of the ,internal ,revenue ,code of #aihf71 include a link to the website 7or other successor technology7 where rate and payment information required to be made public under subsection 7c7 may be accessed4 7e7 ,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 7b71 and rate and payment information made public under subsection 7c71 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 7f7 ,definitions ,in this section3 7#a7 ,applicable spread price drug ,the term applicable spread price drug means1 with respect to a group health plan or group or individual health insurance coverage1 a drug for which benefits are available under such plan or coverage and with respect to which1 at the time rate and payment information is made public by such plan under subsection 7c7-- 7,a7 a contract is in effect between an entity providing pharmacy benefit management services on behalf of such plan or coverage and a pharmacy for the dispensing of such drug under such plan or coverage2 and 7,b7 the specified payment amount for such drug so dispensed is less than the specified reimbursement amount for such drug so dispensed4 7#b7 ,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 7#c7 ,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 7as defined in paragraph 7#d77 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 respectively4 7#d7 ,provider ,the term provider includes a health care facility and a pharmacy4 7#e7 ,specified payment amount ,the term specified payment amount means1 with respect to a drug to be dispensed by a pharmacy to a participant1 beneficiary1 or enrollee of a group health plan or group or individual health insurance coverage where such pharmacy has in effect a contract with an entity providing pharmacy benefit management services on behalf of such plan or coverage for the dispensing of such drug under such plan or coverage1 the amount that such entity has agreed to pay such pharmacy for the ingredient costs and any applicable dispensing fee for such drug 7or the amount that such entity has agreed to pay such pharmacy for such drug under any other compensation structure specified by the ,secretary7 under such contract1 taking into account any cost sharing requirement applicable to such drug and participant1 beneficiary1 or enrollee4 7#f7 ,specified reimbursement amount ,the term specified reimbursement amount means1 with respect to a drug to be dispensed by a pharmacy to a participant1 beneficiary1 or enrollee of a group health plan or group or individual health insurance coverage where such pharmacy has in effect a contract with an entity providing pharmacy benefit management services on behalf of such plan or coverage for the dispensing of such drug under such plan or coverage1 the amount that such plan or coverage has agreed to pay to such entity for the ingredient costs and any applicable dispensing fee for such drug 7or the amount that such plan or coverage has agreed to pay such entity for such drug under any other compensation structure specified by the ,secretary71 taking into account any cost sharing requirement applicable to such drug and participant1 beneficiary1 or enrollee4 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-- 7i7 in the header1 by striking ,maintenance of price comparison tool and inserting ,transparency in coverage2 7ii7 by striking ,a group health plan and inserting the following3 7a7 ,maintenance of price comparison tool for plan years before #bjbi 7#a7 ,in general ,a group health plan 2 7iii7 in subsection 7a71 as inserted by clause 7ii71 by adding at the end the following new paragraph3 7#b7 ,sunset ,paragraph 7#a7 shall not apply with respect to plan years beginning on or after ,january #a1 #bjbi4 2 and 7iv7 by adding at the end the following new subsections3 7b7 ,cost-,sharing transparency 7#a7 ,in general ,for plan years beginning on or after ,january #a1 #bjbi1 a group health plan and a health insurance issuer offering group health insurance coverage shall provide a participant or beneficiary1 in a timely manner upon request of the participant or beneficiary1 information on 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 provider4 ,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 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 a participant and such participant's 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 financial incentives 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,h7 ,other information determined appropriate by the ,secretary4 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 is made available in plain language at no cost2 7,c7 provides for real-time responses to requests described in paragraph 7#a72 7,d7 is updated in a manner such that information provided through such tool is timely and accurate at the time such request is made2 7,e7 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 7ii7 all providers that are participating providers with respect to such item or service2 or 7iii7 nonspecific providers located in a relevant geographic region that are not participating providers with respect to such item or service2 7,f7 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,g7 meets any other requirement determined appropriate by the ,secretary1 including requirements to ensure the accessibility and usability of information provided through such tool4 7c7 ,rate and payment information 7#a7 ,in general ,for plan years beginning on or after ,january #a1 #bjbi1 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 shall 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 coverage-- 7i7 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 service 7other than1 in the case that such plan or coverage provides benefits for such item or service only when furnished by a specific type of provider1 such a participating provider who is not such type of provider 7referred to in this subparagraph as an excluded provider772 and 7ii7 with respect to each such participating provider 7other than a provider that is an excluded provider with respect to such item or service71 an indication of whether1 during the #a-year period beginning #ah months before the date such information is made public1 such provider submitted a claim for such item or service to such plan or coverage for which payment was made 7in whole or in part7 under such plan or coverage4 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 7ii7 the average amount paid by such plan or coverage 7accounting for1 in a manner determined appropriate by the ,secretary1 rebates1 discounts1 price concessions1 and any other remuneration specified by the ,secretary7 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 unless fewer than #bj claims for such drug were submitted to such plan or coverage during such period2 and 7iii7 in the case such drug is an applicable spread price drug dispensed by a pharmacy-- 7,i7 a specification that such drug is such an applicable spread price drug2 and 7,,ii7 for each pharmacy that has a contractual relationship for dispensing such drug under such plan or coverage1 a specification of the difference 7if any7 between the specified payment amount for such drug so dispensed by such pharmacy and the specified reimbursement amount for such drug so dispensed by such pharmacy4 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 plan or coverage1 for each such item or service furnished during the #f-month period beginning #i months before the date such information is made public by a provider that was not a participating provider with respect to such item or service1 broken down by each such provider1 other than such an amount with respect to an item or service for which1 during such period1 fewer than #aa claims were made under such plan or coverage4 ,in determining the number of claims made under such plan or coverage with respect to an item or service during such period for purposes of the preceding sentence1 such number shall be deemed to include all claims for such item or service made during such period under all group health plans and health insurance coverage offered in the same insurance market 7specified in subclause 7,i71 7,,ii71 7,,iii71 or 7,,iv7 of section #gaf7;a77#c77;,e77iv77 by the sponsor or issuer 7as applicable7 of the plan or coverage at issue4 ,in the case that a specific dollar amount for an in-network rate required to be made available pursuant to this subsection with respect to an item or service cannot be determined prospectively on the basis that such rate is determined as a percentage of the billed charges for such item or service1 such percentage and the median amount recognized by such plan or coverage as payment for such item or service with respect to claims for such item or service submitted by participating providers during the period described in subparagraph 7,a77ii7 shall be reported by such plan or coverage in lieu of such rate4 ,such plan or coverage shall identify that such median amount represents an estimate of such in-network rate for such item or service4 7#c7 ,manner of publication 7,a7 ,in general ,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 as applicable1 such as application programming 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 7which may be so specified through subregulatory guidance71 including requirements relating to whether such information should be so made available on the plan or coverage level1 with respect to individual provider networks1 or aggregated in such manner as specified by the ,secretary4 ,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,b7 ,timing ,rate and payment information described in paragraph 7#b7 shall be made public on a quarterly basis4 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 #bjbi1 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 or capitated rate-- 7i7 a description of the formulae1 pricing methodologies1 or other information used to calculate the payment rate for such rate2 and 7ii7 a list of the items and services included in such rate4 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 7d7 ,attestation ,each group health plan and health insurance issuer offering group health insurance coverage shall annually submit to the ,secretary an attestation1 signed by the chief executive officer1 chief financial officer1 or other comparable official 7as specified by the ,secretary7 of such plan or issuer1 of such plan's or coverage's compliance with the provisions of this section and that information made available under this section is true1 accurate1 and complete4 ,such attestation shall1 except in the case of a grandfathered health plan 7as defined in section #abea7;e7 of the ,patient ,protection and ,affordable ,care ,act71 include a link to the website 7or other successor technology7 where rate and payment information required to be made public under subsection 7c7 may be accessed4 7e7 ,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 7b71 and rate and payment information made public under subsection 7c71 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 7f7 ,definitions ,in this section3 7#a7 ,applicable spread price drug ,the term applicable spread price drug means1 with respect to a group health plan or group health insurance coverage1 a drug for which benefits are available under such plan or coverage and with respect to which1 at the time rate and payment information is made public by such plan under subsection 7c7-- 7,a7 a contract is in effect between an entity providing pharmacy benefit management services on behalf of such plan or coverage and a pharmacy for the dispensing of such drug under such plan or coverage2 and 7,b7 the specified payment amount for such drug so dispensed is less than the specified reimbursement amount for such drug so dispensed4 7#b7 ,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 7#c7 ,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 health insurance coverage1 a physician or other health care provider 7as defined in paragraph 7#d77 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 respectively4 7#d7 ,provider ,the term provider includes a health care facility and a pharmacy4 7#e7 ,specified payment amount ,the term specified payment amount means1 with respect to a drug to be dispensed by a pharmacy to a participant or beneficiary of a group health plan or group health insurance coverage where such pharmacy has in effect a contract with an entity providing pharmacy benefit management services on behalf of such plan or coverage for the dispensing of such drug under such plan or coverage1 the amount that such entity has agreed to pay such pharmacy for the ingredient costs and any applicable dispensing fee for such drug 7or the amount that such entity has agreed to pay such pharmacy for such drug under any other compensation structure specified by the ,secretary7 under such contract1 taking into account any cost sharing requirement applicable to such drug and participant or beneficiary4 7#f7 ,specified reimbursement amount ,the term specified reimbursement amount means1 with respect to a drug to be dispensed by a pharmacy to a participant or beneficiary of a group health plan or group health insurance coverage where such pharmacy has in effect a contract with an entity providing pharmacy benefit management services on behalf of such plan or coverage for the dispensing of such drug under such plan or coverage1 the amount that such plan or coverage has agreed to pay to such entity for the ingredient costs and any applicable dispensing fee for such drug 7or the amount that such plan or coverage has agreed to pay such entity for such drug under any other compensation structure specified by the ,secretary71 taking into account any cost sharing requirement applicable to such drug and participant or beneficiary4 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 #bjbi1 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 or 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 providers 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 or 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 #bjbi1 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 #bjbi1 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 #bjbi4 #d4 ,information on prescription drugs 7a7 ,,phsa 7#a7 ,in general ,part ,d of title ,,xxvii of the ,public ,health ,service ,act is 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 seq47 is 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 seq47 is 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 #aihf is 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 #aihf is amended by adding at the end the following new item3 ,sec4 #ihbg4 ,information on prescription drugs4 4 #e4 ,vertical integration accountability 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 #bjbh 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 with respect to such plan year to such specified health care providers that have in effect a financial risk arrangement with respect to such plan year2 7iii7 the total amount of recoupments collected with respect to such plan year from such specified health care providers that have in effect a financial risk arrangement with respect to such plan year2 7iv7 the total amount of incentive-based payments made with respect to such plan year to providers of services and suppliers not that are not specified health care providers and that have in effect a financial risk arrangement with respect to such plan year2 and 7v7 the total amount of recoupments collected with respect to such plan year from such providers of services and suppliers that have in effect a financial risk arrangement with respect to 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 across all ,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 that-- 7,i7 is owned by1 controlled by1 or related under a common ownership structure with such ,,ma organization2 7,,ii7 has in effect a contract solely with such organization 7or with an entity owned by1 controlled by1 or related under a common ownership structure with such organization 7or that has in effect any comparable arrangement with such organization77 for furnishing items and services2 7,,iii7 is a partner under a partnership 7as defined in section #ggja7;a77#b7 of the ,internal ,revenue ,code of #aihf7 with such organization 7or with any an entity owned by1 controlled by1 or related under a common ownership structure with such organization72 or 7,,iv7 through contract1 ownership1 or otherwise-- 7aa7 directly or indirectly controls1 is controlled by1 or is under common ownership with such organization 7or with an entity owned by1 controlled by1 or related under a common ownership structure with such organization72 7bb7 is part of a controlled group of corporations under section #aefc of the ,internal ,revenue ,code of #aihf with such organization 7or with any such entity72 7cc7 is a participant in a lawful combination under which such provider or supplier shares substantial financial risk in connection with such organization's operations 7or with the operations of any such entity72 or 7dd7 part of an affiliated service group under section #dad of such ,code with such organization 7or with any such entity74 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 #bjbh 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 plan during such year4 7,b7 ,definition ,for purposes of this paragraph1 the term specified pharmacy means1 with respect to a prescription drug plan offered by a ,,pdp sponsor and a plan year1 a pharmacy that-- 7i7 is owned by1 controlled by1 or related under a common ownership structure with such sponsor2 7ii7 has in effect a contract solely with such sponsor 7or with an entity owned by1 controlled by1 or related under a common ownership structure with such sponsor 7or that has in effect any comparable arrangement with such sponsor77 for dispensing covered part ,d drugs2 7iii7 is a partner under a partnership 7as defined in section #ggja7;a77#b7 of the ,internal ,revenue ,code of #aihf7 with such sponsor 7or with any an entity owned by1 controlled by1 or related under a common ownership structure with such sponsor72 or 7iv7 through contract1 ownership1 or otherwise-- 7,i7 directly or indirectly controls1 is controlled by1 or is under common ownership with such sponsor 7or with an entity owned by1 controlled by1 or related under a common ownership structure with such sponsor72 7,,ii7 is part of a controlled group of corporations under section #aefc of the ,internal ,revenue ,code of #aihf with such sponsor 7or with any such entity72 7,,iii7 is a participant in a lawful combination under which such provider or supplier shares substantial financial risk in connection with such sponsor's operations 7or with the operations of any such sponsor72 or 7,,iv7 part of an affiliated service group under section #dad of such ,code with such sponsor 7or with any such entity74 4 7b7 ,reports on vertical integration under ,medicare 7#a7 ,in general ,not later than the first ,june #ae occurring on or after the date that is #b years after the ,secretary of ,health and ,human ,services first makes available information submitted under sections #aheg7;e77#f7 and #ahfj;,d-#ab7;b77#i7 of the ,social ,security ,act 7as added by paragraphs 7#a7 and 7#b71 respectively1 of subsection 7a77 to the ,medicare ,payment ,advisory ,commission1 and again not later than #d years after the first report is submitted under this paragraph1 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 program under part ,c of title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba et seq47 or part ,d of such title 7#db ,u4,s4,c4 #aciew-#aja et seq471 including health care providers1 pharmacies1 prescription drug plan sponsors1 ,medicare ,advantage organizations1 and pharmacy benefit managers4 ,such report shall include1 to the extent practicable-- 7,a7 with respect to ,medicare ,advantage organizations1 the evaluation described in paragraph 7#b72 7,b7 with respect to prescription drug plans1 pharmacy benefit managers1 and pharmacies1 the comparisons and summary described in paragraph 7#c72 7,c7 an assessment of the ,medicare ,advantage organization and ,,pdp sponsor integration information described in paragraph 7#d72 and 7,d7 an analysis of the impact of such integration on health care access1 price1 quality1 and outcomes4 7#b7 ,medicare ,advantage organizations ,for purposes of paragraph 7#a77;,a71 the evaluation described in this paragraph 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 provider1 compared to the average number of such diagnoses made during such year with respect to enrollees of such plan who1 during such year1 did not receive such an assessment from such a provider2 7,b7 the average risk score for enrollees of a ,medicare ,advantage plan who received such an assessment from a specified health care provider during such year compared to the average risk score for enrollees of such plan who did not receive such an assessment from such a provider during such year2 7,c7 any relationship between risk scores for such enrollees receiving such an assessment from such a provider during such year and incentive-based 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 year compared to the average risk score for enrollees of such plan who did not receive any item or service from such a 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-based payments made under the plan to specified providers4 7#c7 ,prescription drug plans ,for purposes of paragraph 7#a77;,b71 the comparisons and summary described in this paragraph 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 information about payments submitted with respect to such plan under section #ahfj;,d-#ab7;h77#a77;,c77i77,i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aab7;h77#a77;,c77i77,i77 with respect to specified pharmacies with the same such information about payments submitted by such plan with respect to in-network pharmacies that are not specified pharmacies4 7,b7 ,comparisons of the following3 7i7 ,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 7ii7 ,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 ,a summary of the total manufacturer-derived revenue retained by pharmacy benefit managers and any affiliates of such pharmacy benefit managers 7as reported under section #ahfj;,d-#ab7;h77#a77;,c77i77,i77kk7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aab7;h77#a77;,c77i77,i77kk774 7#d7 ,medicare ,advantage organization and ,,pdp sponsor integration information ,for purposes of paragraph 7#a77;,c71 the ,medicare ,advantage organization and ,,pdp sponsor integration information described in this paragraph is information submitted under sections #aheg7;e77#f7 and #ahfj;,d-#ab7;b77#i7 of the ,social ,security ,act 7as added by paragraphs 7#a7 and 7#b71 respectively1 of subsection 7a77 and section#ahfj;,d-#ab7;h7 of such ,act 7#db ,u4,s4,c4 #aciew-#aab7;h774 7#e7 ,definitions ,in this subsection3 7,a7 ,applicable year ,the term applicable year means-- 7i7 with respect to the first report submitted under paragraph 7#a71 plan year #bjbh2 and 7ii7 with respect to the second report submitted under paragraph 7#a71 plan year #bjca4 7,b7 ,covered part ,d drug ,the term covered part ,d drug has the meaning given such term in section #ahfj;,d-#b7;e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ajb7;e774 7,c7 ,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#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acjew-#bc7;a77#c774 7,d7 ,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 subparagraph 7,e74 7,e7 ,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 that-- 7i7 is owned by1 controlled by1 or related under a common ownership structure with such organization2 7ii7 has in effect a contract solely with such organization 7or with an entity owned by1 controlled by1 or related under a common ownership structure with such organization 7or that has in effect any comparable arrangement with such organization77 for furnishing items and services2 7iii7 is a partner under a partnership 7as defined in section #ggja7;a77#b7 of the ,internal ,revenue ,code of #aihf7 with such organization 7or with any an entity owned by1 controlled by1 or related under a common ownership structure with such organization72 or 7iv7 through contract1 ownership1 or otherwise-- 7,i7 directly or indirectly controls1 is controlled by1 or is under common ownership with such organization 7or with an entity owned by1 controlled by1 or related under a common ownership structure with such organization72 7,,ii7 is part of a controlled group of corporations under section #aefc of the ,internal ,revenue ,code of #aihf with such organization 7or with any such entity72 7,,iii7 is a participant in a lawful combination under which such provider or supplier shares substantial financial risk in connection with such organization's operations 7or with the operations of any such entity72 or 7,,iv7 part of an affiliated service group under section #dad of such ,code with such organization 7or with any such entity74 7,f7 ,specified pharmacy ,the term specified pharmacy means1 with respect to a prescription drug plan offered by a prescription drug plan sponsor1 a pharmacy that-- 7i7 is owned by1 controlled by1 or related under a common ownership structure with such sponsor2 7ii7 has in effect a contract solely with such sponsor 7or with an entity owned by1 controlled by1 or related under a common ownership structure with such sponsor 7or that has in effect any comparable arrangement with such sponsor77 for dispensing covered part ,d drugs2 7iii7 is a partner under a partnership 7as defined in section #ggja7;a77#b7 of the ,internal ,revenue ,code of #aihf7 with such sponsor 7or with any an entity owned by1 controlled by1 or related under a common ownership structure with such sponsor72 or 7iv7 through contract1 ownership1 or otherwise-- 7,i7 directly or indirectly controls1 is controlled by1 or is under common ownership with such sponsor 7or with an entity owned by1 controlled by1 or related under a common ownership structure with such sponsor72 7,,ii7 is part of a controlled group of corporations under section #aefc of the ,internal ,revenue ,code of #aihf with such sponsor 7or with any such entity72 7,,iii7 is a participant in a lawful combination under which such provider or supplier shares substantial financial risk in connection with such sponsor's operations 7or with the operations of any such entity72 or 7,,iv7 part of an affiliated service group under section #dad of such ,code with such sponsor 7or with any such entity74 7,g7 ,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 that-- 7i7 is owned by1 controlled by1 or related under a common ownership structure with such sponsor2 7ii7 has in effect a contract solely with such sponsor 7or with an entity owned by1 controlled by1 or related under a common ownership structure with such sponsor 7or that has in effect any comparable arrangement with such sponsor77 for furnishing pharmacy benefit management services2 7iii7 is a partner under a partnership 7as defined in section #ggja7;a77#b7 of the ,internal ,revenue ,code of #aihf7 with such sponsor 7or with any an entity owned by1 controlled by1 or related under a common ownership structure with such sponsor72 or 7iv7 through contract1 ownership1 or otherwise-- 7,i7 directly or indirectly controls1 is controlled by1 or is under common ownership with such sponsor 7or with an entity owned by1 controlled by1 or related under a common ownership structure with such sponsor72 7,,ii7 is part of a controlled group of corporations under section #aefc of the ,internal ,revenue ,code of #aihf with such sponsor 7or with any such entity72 7,,iii7 is a participant in a lawful combination under which such provider or supplier shares substantial financial risk in connection with such sponsor's operations 7or with the operations of any such entity72 or 7,,iv7 part of an affiliated service group under section #dad of such ,code with such sponsor 7or with any such entity74 #f4 ,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 appropriated-- 7#a7 to the ,secretary of ,health and ,human ,services and the ,secretary of the ,treasury1 #fe1jjj1jjj for fiscal year #bjbg1 to remain available through fiscal year #bjcb2 and 7#b7 to the ,secretary of ,labor1 #ce1jjj1jjj for fiscal year #bjbg1 to remain available through fiscal year #bjcb4 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 not later than ,september #ast of each year1 to the ,committees on ,energy and ,commerce1 on ,ways and ,means1 on ,education and the ,workforce1 and on ,appropriations of the ,house of ,representatives and the ,committees on ,health1 ,education1 ,labor1 and ,pensions1 on ,finance1 and on ,appropriations of the ,senate a report on funds expended pursuant to funds appropriated under this section4