,,ii  #aaith ,,congress  #ast ,session  
,s4 #bcee  ,,in ,,the ,,senate ,,of     
,,the ,,united ,,states  ,july #ag1     
#bjbe,mr4 ,marshall 7for himself1 ,mr4  
,hickenlooper1 ,mr4 ,grassley1 ,ms4     
,hassan1 ,mr4 ,sheehy1 and ,ms4 ,ernst7 
introduced the following bill2 which was
 read twice and referred to the         
,committee on ,health1 ,education1      
,labor1 and ,pensions  ,a ,,bill  ,to   
amend the ,public ,health ,service ,act 
to provide for hospital and insurer     
price transparency4  #a4 ,short title   
,this ,act may be cited as the ,patients
 ,deserve ,price ,tags ,act4  #b4       
,strengthening hospital price           
transparency requirements  7a7 ,in      
general ,section #bgah7;e7 of the       
,public ,health ,service ,act 7#db      
,u4,s4,c4 #cjj;gg-#ah7;e77 is amended to
 read as follows3  7e7 ,standard        
hospital charges  7#a7 ,in general  7,a7
 ,disclosure of standard charges ,each  
hospital shall1 in accordance with a    
method and format established by the    

,secretary under subparagraph 7,c71 on a
 monthly basis compile and make public  
7without subscription and free of       
charge7-- 7i7 all of the hospital's     
standard charges 7including the         
information described in subparagraph   
7,b77 for each item and service         
furnished by such hospital2 and  7ii7   
hospital standard charge information1   
including the information described in  
subparagraph 7,b71 in a                 
consumer-friendly format 7as specified  
by the ,secretary71 that includes-- 7,i7
 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 services through ,december    
#ca1 #bjbf1 after which the hospital's  
prices shall include all shoppable      

services2 and  7,,ii7 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 furnished4  7,b7 ,standard charges   
described ,for purposes of subparagraph 
7,a71 standard charges means3 7i7 ,a    
plain language description of each item 
or service1 accompanied by any          
applicable billing codes1 including     
modifiers1 using commonly recognized    
billing code sets1 including the        
,current ,procedural ,terminology code1 
the ,healthcare ,common ,procedure      
,coding ,system code1 the               
diagnosis-related group1 the ,national  
,drug ,code1 and other nationally       
recognized identifier4  7ii7 ,the gross 
charge1 expressed as a dollar amount1   
for each such item or service1 when     
provided in1 as applicable1 the         
inpatient setting and outpatient        
department setting4  7iii7 ,the         
discounted cash price expressed as a    

dollar amount1 for each such item or    
service when provided in1 as applicable1
 the inpatient setting and outpatient   
department setting 7or1 in the case no  
discounted cash price is available for  
an item or service1 the minimum cash    
price accepted by the hospital from     
self-pay individuals for such item or   
service1 expressed as a dollar amount1  
as well as1 with respect to prices made 
public pursuant to subparagraph         
7,a77ii71 a link to a consumer-friendly 
document that clearly explains the      
hospital's charity care policy74 ,the   
hospital shall accept the discounted    
cash price as payment in full from any  
patient that chooses to pay in cash     
without regard to the patient's         
coverage4  7iv7 ,the payer-specific     
negotiated charges1 expressed as a      
dollar amount and clearly associated    
with the name of the applicable third   
party payer and name of each plan1 that 
apply to each such item or service when 
provided in1 as applicable1 the         

inpatient setting and outpatient        
department setting4 ,if the charges are 
based on an algorithm1 percentage of    
another amount1 or other formula or     
criteria1 the hospital also shall       
disclose such algorithm1 percentage1    
formula1 or criteria as set forth in its
 contract and any other terms1          
schedules1 exhibits1 data1 or other     
information referenced in any such      
contract as shall be required to        
determine and disclose the negotiated   
charge4  7v7 ,the de-identified maximum 
and minimum negotiated charges for each 
such item or service1 expressed as a    
non-zero dollar amount4  7vi7 ,any other
 additional information the ,secretary  
may require for the purpose of improving
 the accuracy of1 or enabling consumers 
to easily understand and compare1       
standard charges and prices for an item 
or service1 except information that is  
duplicative of any other reporting      
requirement under this subsection4 ,in  
the case of standard charges and prices 

for an item or service included as part 
of a bundled1 per diem1 episodic1 or    
other similar arrangement1 the          
information described in this           
subparagraph shall be made available as 
determined appropriate by the           
,secretary4  7,c7 ,uniform method and   
format ,not later than ,january #a1     
#bjbf1 the ,secretary shall establish a 
standard1 uniform method and format for 
hospitals to use in compiling and making
 public standard charges pursuant to    
subparagraph 7,a77i7 and a standard1    
uniform method and format for such      
hospitals to use in compiling and making
 public prices pursuant to subparagraph 
7,a77ii74 ,such methods and formats     
shall-- 7i7 in the case of such method  
and format for making public standard   
charges pursuant to subparagraph        
7,a77i71 ensure that such charges are   
made available in a machine-readable    
spreadsheet format2  7ii7 meet such     
standards as determined appropriate by  
the ,secretary in order to ensure the   

accessibility and usability of such     
charges and prices2 and  7iii7 be       
updated as determined appropriate by the
 ,secretary1 in consultation with       
stakeholders4  7#b7 ,no deemed          
compliance ,the availability of a price 
estimator tool shall not be considered  
to deem compliance with or otherwise    
vitiate the requirements of paragraph   
7#a77;,a77ii7 or any other requirements 
of this section4 ,furthermore1 the use  
of an estimator tool shall not be used  
for purposes of compliance with any     
provisions in this ,section4  7#c7      
,monitoring compliance ,the ,secretary  
shall1 in consultation with the         
,inspector ,general of the ,department  
of ,health and ,human ,services1        
establish a process to monitor          
compliance with this subsection4 ,such  
process shall ensure that each          
hospital's compliance with this         
subsection is reviewed not less         
frequently than once every year4  7#d7  
,attestation ,a senior official from    

each hospital 7the ,chief ,executive    
,officer1 ,chief ,financial ,officer1 or
 an official of equivalent seniority7   
shall attest to the accuracy and        
completeness of the disclosures made in 
accordance with the hospital price      
transparency requirements set forth in  
this regulation4 ,such attestation shall
 be deemed to be material to payment    
from the ,federal ,government to the    
hospital4  7#e7 ,enforcement  7,a7 ,in  
general ,in the case of a hospital that 
fails to comply with the requirements of
 this subsection1 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    
determination1 which shall include a    
request for a corrective action plan to 
comply with such requirements4  7,b7    
,civil monetary penalty  7i7 ,in general
 ,in addition to any other enforcement  
actions or penalties that may apply     
under another provision of law1 a       

hospital that has received a request for
 a corrective action plan under         
subparagraph 7,a7 and fails to comply   
with the requirements of this subsection
 by the date that is #de days after such
 request is made shall be subject to a  
civil monetary penalty of an amount     
specified by the ,secretary for each day
 7beginning with the day on which the   
,secretary first determined that such   
hospital was not complying with such    
requirements7 during which such failure 
was ongoing4 ,such amount shall not     
exceed-- 7,i7 in the case of a hospital 
with #cj or fewer beds1 #cjj per day2   
7,,ii7 in the case of a hospital with   
more than #cj beds but fewer than #aja  
beds1 #ab4ej per bed per day 7or1 in the
 case of such a hospital that has been  
noncompliant with such requirements for 
a #a-year period or longer1 beginning   
with the first day following such       
#a-year period1 #ae per bed per day72   
7,,iii7 in the case of a hospital with  
more than #ajj beds but fewer than #cja 

beds1 #ag4ej per bed per day 7or1 in the
 case of such a hospital that has been  
noncompliant with such requirements for 
a #a-year period or longer1 beginning   
with the first day following such       
#a-year period1 #bj per bed per day72   
7,,iv7 in the case of a hospital with   
more than #cjj beds but fewer than #eja 
beds1 #bj per bed per day 7or1 in the   
case of such a hospital that has been   
noncompliant with such requirements for 
a #a-year period or longer1 beginning   
with the first day following such       
#a-year period1 #be per bed per day72   
and  7,v7 in the case of a hospital with
 more than #ejj beds1 #be per bed per   
day 7or1 in the case of such a hospital 
that has been noncompliant with such    
requirements for a #a-year period or    
longer1 beginning with the first day    
following such #a-year period1 #ce per  
bed per day74  7ii7 ,increase authority 
,in applying this subparagraph with     
respect to violations occurring in #bjbg
 or a subsequent year1 the ,secretary   

may through notice and comment          
rulemaking increase-- 7,i7 the          
limitation on the per day amount of any 
penalty applicable to a hospital under  
clause 7i77,i72  7,,ii7 the limitations 
on the per bed per day amount of any    
penalty applicable under any of         
subclauses 7,,ii7 through 7,v7 of clause
 7i72 and  7,,iii7 the limitation on the
 increase of any penalty applied under  
clause 7iii7 pursuant to the amounts    
specified in subclause 7,,ii7 of such   
clause4  7iii7 ,persistent noncompliance
  7,i7 ,in general ,in the case of a    
hospital that the ,secretary has        
determined to be knowingly and willfully
 noncompliant with the provisions of    
this subsection two or more times during
 a #a-year period1 the ,secretary may   
increase any penalty otherwise          
applicable under this subparagraph by   
the amount specified in subclause 7,,ii7
 with respect to such hospital and may  
require such hospital to complete such  
additional corrective actions plans as  

the ,secretary may specify4  7,,ii7     
,specified amount ,for purposes of      
subclause 7,i71 the amount specified in 
this subclause is1 with respect to a    
hospital-- 7aa7 with more than #cj beds 
but fewer than #aja beds1 an amount that
 is not less than #ejj1jjj and not more 
than #a1jjj1jjj2  7bb7 with more than   
#ajj beds but fewer than #cja beds1 an  
amount that is greater than #a1jjj1jjj  
and not more than #b1jjj1jjj2  7cc7 with
 more than #cjj beds but fewer than #eja
 beds1 an amount that is greater than   
#b1jjj1jjj and not more than #d1jjj1jjj2
 and  7dd7 with more than #ejj beds1 and
 amount that is not less than #e1jjj1jjj
 and not more than #aj1jjj1jjj4  7iv7   
,provision of technical assistance ,the 
,secretary may1 to the extent           
practicable1 provide technical          
assistance relating to compliance with  
the provisions of this section to       
hospitals requesting such assistance4   
7v7 ,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 ,no waiver ,the     
,secretary shall not grant or extend any
 waiver1 delay1 tolling1 or other       
mitigation of a civil monetary penalty  
for violation of this subsection4  7#f7 
,definitions ,for purposes of this      
subsection3 7,a7 ,discounted cash price 
,the term discounted cash price means   
the minimum charge1 exclusive of any    
hospital or third-party payer           
assistance1 that the hospital accepts   
from an individual who pays cash1 or    
cash equivalent1 for a                  
hospital-furnished item or service1     
without regard to patient coverage1 as  
payment in full4  7,b7 ,gross charge    
,the term gross charge means the charge 
for an individual item or service that  
is reflected on a hospital's            

chargemaster1 absent any discounts4     
7,c7 ,hospital ,the term hospital means 
a hospital 7as defined in section       
#ahfa7;e7 of the ,social ,security      
,act71 a critical access hospital 7as   
defined in section #ahfa7mmm77#a7 of the
 ,social ,security ,act71 or a rural    
emergency hospital 7as defined in       
section #ahfa7kkk7 of the ,social       
,security ,act71 together with any      
parent1 subsidiary1 or other affiliated 
provider or supplier of health care     
items and services without regard to    
whether such parent1 subsidiary1 or     
other affiliated provider or supplier   
operates under separate licensure1      
certification1 or designation4  7,d7    
,payer-specific negotiated charge ,the  
term payer-specific negotiated charge   
means the charge that a hospital has    
negotiated with a third party payer for 
an item or service4  7,e7 ,shoppable    
service ,the term shoppable service     
means a service that can be scheduled by
 a health care consumer in advance and  

includes all ancillary items and        
services customarily furnished as part  
of such service4  7,f7 ,third party     
payer ,the term third party payer means 
an entity that is1 by statute1 contract1
 or agreement1 legally responsible for  
payment of a claim for a health care    
item or service4  7#g7 ,rulemaking ,the 
,secretary shall implement this         
subsection through notice and comment   
rulemaking in accordance with section   
#eec of title #e1 ,united ,states ,code4
  4  7b7 ,effective date  7#a7 ,in      
general ,the amendment made by          
subsection 7a7 shall apply beginning    
,january #a1 #bjbf4  7#b7 ,continued    
applicability of rules for previous     
years ,nothing in the amendment made by 
this section may be construed as        
affecting the applicability of the      
regulations codified at part #ahj of    
title #de1 ,code of ,federal            
,regulations1 before ,january #a1 #bjbe4
  7c7 ,continued applicability of state 
law ,the provisions of this ,act shall  

not supersede any provision of ,state   
law that establishes1 implements1 or    
continues in effect any requirement or  
prohibition related to health care price
 transparency1 except to the extent that
 such requirement or prohibition        
prevents the application of a           
requirement or prohibition of this ,act4
  #c4 ,increasing price transparency of 
clinical diagnostic laboratory tests    
,section #bgah of the ,public ,health   
,service ,act 7#db ,u4,s4,c4            
#cjj;gg-#ah7 is amended by adding at the
 end the following3  7f7 ,clinical      
diagnostic laboratory price transparency
  7#a7 ,in general ,beginning ,july #a1 
#bjbg1 an applicable laboratory shall-- 
7,a7 make publicly available on an      
internet website the information        
described in paragraph 7#b7 with respect
 to each such specified clinical        
diagnostic laboratory test that such    
laboratory so furnishes2 and  7,b7      
ensure that such information is updated 
not less frequently than monthly1 if    

there have been any changes to such     
information4  7#b7 ,information         
described ,for purposes of paragraph    
7#a71 the information described in this 
paragraph is1 with respect to an        
applicable laboratory and a specified   
clinical diagnostic laboratory test1 the
 following3 7,a7 ,a plain language      
description of each item or service1    
accompanied by any applicable billing   
codes1 including modifiers1 using       
commonly recognized billing code sets1  
including the ,current ,procedural      
,terminology code1 the ,healthcare      
,common ,procedure ,coding ,system code1
 the diagnosis-related group1 the       
,national ,drug ,code1 and other        
nationally recognized identifier4  7,b7 
,the gross charge expressed as a dollar 
amount1 for each such item or service4  
7,c7 ,the discounted cash price         
expressed as a dollar amount1 for each  
such item or service 7or1 in the case no
 discounted cash price is available for 
an item or service1 the minimum cash    

price accepted by the laboratory from   
self-pay individuals for such item or   
service when provided in such settings  
for the previous three years1 expressed 
as a dollar amount1 as well as1 with    
respect to prices made public pursuant  
to subparagraph 7,a77ii71 a link to a   
consumer-friendly document that clearly 
explains the laboratory's charity care  
policy74 ,the laboratory shall accept   
the discounted or minimum cash price as 
payment in full from any patient that   
chooses to pay in cash without regard to
 the patient's coverage4  7,d7 ,the     
payer-specific negotiated charges1      
expressed as a dollar amount and clearly
 associated with the name of the        
applicable third party payer and name of
 each plan1 that apply to each such item
 or service when provided in1 as        
applicable1 the inpatient setting and   
outpatient department setting4 ,if the  
charges are based on an algorithm1      
percentage of another amount1 or other  
formula or criteria1 the clinical       

diagnostic laboratory also shall        
disclose such algorithm1 percentage1    
formula1 or criteria as set forth in its
 contract and any other terms1          
schedules1 exhibits1 data1 or other     
information referenced in any such      
contract as shall be required to        
determine and disclose the negotiated   
charge4  7,e7 ,the de-identified maximum
 and minimum negotiated charges for each
 such item or service1 expressed as a   
non-zero dollar amount4  7,f7 ,any other
 additional information the ,secretary  
may require for the purpose of improving
 the accuracy of1 or enabling consumers 
to easily understand and compare1       
standard charges and prices for an item 
or service1 except information that is  
duplicative of any other reporting      
requirement under this subsection4 ,in  
the case of standard charges and prices 
for an item or service included as part 
of a bundled1 per diem1 episodic1 or    
other similar arrangement1 the          
information described in this           

subparagraph shall be made available as 
determined appropriate by the           
,secretary4  7#c7 ,uniform method and   
format ,not later than ,january #a1     
#bjbg1 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 shall-- 7,a7 include a      
machine-readable spreadsheet format     
containing the information described in 
paragraph 7#b7 for all items and        
services furnished by each laboratory2  
7,b7 meet such standards as determined  
appropriate by the ,secretary in order  
to ensure the accessibility and         
usability of such information2 and  7,c7
 be updated as determined appropriate by
 the ,secretary1 in consultation with   
stakeholders4  7#d7 ,inclusion of       
ancillary services ,any price or rate   
for a specified clinical diagnostic     
laboratory test available to be         
furnished by an applicable laboratory   

made publicly available in accordance   
with paragraph 7#a7 shall include the   
price or rate for any ancillary item or 
service 7including specimen collection  
services1 specimen transport1           
centrifugation1 aliquoting1 labeling1   
requisition processing1 and standard    
result reporting services7 that would   
customarily and routinely be furnished  
by such laboratory as part of such test1
 as specified by the ,secretary4  7#e7  
,enforcement  7,a7 ,in general ,in the  
case that the ,secretary determines that
 an applicable laboratory is not in     
compliance with paragraph 7#a7-- 7i7 not
 later than #cj days after such         
determination1 the ,secretary shall     
notify such laboratory of such          
determination2 and  7ii7 if such        
laboratory continues to fail to comply  
with such paragraph after the date that 
is #ij days after such notification is  
sent1 the ,secretary may impose a civil 
monetary penalty in an amount not to    
exceed #cjj for each day 7beginning with

 the day on which the ,secretary first  
determined that such laboratory was     
failing to comply with such paragraph7  
during which such failure is ongoing4   
7,b7 ,increase authority ,in applying   
this paragraph with respect to          
violations occurring in #bjbh or a      
subsequent year1 the ,secretary may     
through notice and comment rulemaking   
increase the per day limitation on civil
 monetary penalties under subparagraph  
7,a77ii74  7,c7 ,application of certain 
provisions ,the provisions of section   
#aabh;,a of the ,social ,security ,act  
7other than subsections 7a7 and 7b7 of  
such section7 shall apply to a civil    
monetary penalty imposed under this     
paragraph in the same manner as such    
provisions apply to a civil monetary    
penalty imposed under subsection 7a7 of 
such section4  7#f7 ,provision of       
technical assistance ,the ,secretary    
shall1 to the extent practicable1       
provide technical assistance relating to
 compliance with the provisions of this 

subsection to applicable laboratories   
requesting such assistance4  7#g7       
,definitions ,in this subsection3 7,a7  
,applicable laboratory ,the term        
applicable laboratory means a laboratory
 as such term is defined in section     
#dic4b1 of title #db1 ,code of ,federal 
,regulations 7or a successor            
regulation71 except that such term does 
not include a laboratory with respect to
 which standard charges and prices for  
specified clinical diagnostic laboratory
 tests furnished by such laboratory are 
made available by a hospital pursuant to
 subsection 7e7 of this section4  7,b7  
,discounted cash price ,the term        
discounted cash price means the charge  
that applies to an individual who pays  
cash1 or cash equivalent1 for an item or
 service4  7,c7 ,gross charge ,the term 
gross charge means the charge for an    
individual item or service that is      
reflected on an applicable laboratory's 
chargemaster1 absent any discounts4     
7,d7 ,payer-specific negotiated charge  

,the term payer-specific negotiated     
charge means the charge that an         
applicable laboratory has negotiated    
with a third party payer for an item or 
service4  7,e7 ,specified clinical      
diagnostic laboratory test ,the term    
specified clinical diagnostic laboratory
 test means a clinical diagnostic       
laboratory test that is included on the 
list of shoppable services specified by 
the ,centers for ,medicare  ,medicaid   
,services 7as described in subsection   
7e7 of this section71 other than such a 
test that is only available to be       
furnished by a single provider of       
services or supplier4  7,f7 ,third party
 payer ,the term third party payer means
 an entity that is1 by statute1         
contract1 or agreement1 legally         
responsible for payment of a claim for a
 health care item or service4  7#h7     
,rulemaking ,the ,secretary shall       
implement this subsection through notice
 and comment rulemaking in accordance   
with section #eec of title #e1 ,united  

,states ,code4  4  #d4 ,imaging         
transparency ,section #bgah of the      
,public ,health ,service ,act 7#db      
,u4,s4,c4 #cjj;gg-#ah71 as amended by   
section #c1 is further amended by adding
 at the end the following3  7g7 ,imaging
 services price transparency  7#a7 ,in  
general ,beginning ,july #a1 #bjbg1 each
 provider of services or supplier that  
furnishes a specified imaging service1  
other than such a provider or supplier  
with respect to which standard charges  
and prices for such services furnished  
by such provider or supplier are made   
available by a hospital pursuant to     
subsection 7e71 shall-- 7,a7 make       
publicly available 7in accordance with  
paragraph 7#c77 on an internet website  
the information described in paragraph  
7#b7 with respect to each such service  
that such provider of services or       
supplier furnishes2 and  7,b7 ensure    
that such information is updated not    
less frequently than annually4  7#b7    
,information described ,for purposes of 

paragraph 7#a71 the information         
described in this paragraph is1 with    
respect to a provider of services or    
supplier and a specified imaging        
service1 the following3 7,a7 ,a plain   
language description of each item or    
service1 accompanied by any applicable  
billing codes1 including modifiers1     
using commonly recognized billing code  
sets1 including the ,current ,procedural
 ,terminology code1 the ,healthcare     
,common ,procedure ,coding ,system code1
 the diagnosis-related group1 the       
,national ,drug ,code1 and other        
nationally recognized identifier4  7,b7 
,the gross charge expressed as a dollar 
amount1 for each such item or service4  
7,c7 ,the discounted cash price         
expressed as a dollar amount1 for each  
such item or service 7or1 in the case no
 discounted cash price is available for 
an item or service1 the minimum cash    
price accepted by the provider of       
services or supplier from self-pay      
individuals for such item or service    

when provided in such settings for the  
previous three years1 expressed as a    
dollar amount1 as well as1 with respect 
to prices made public pursuant to       
subparagraph 7,a77ii71 a link to a      
consumer-friendly document that clearly 
explains the provider of services or    
supplier's charity care policy74 ,the   
provider of services or supplier shall  
accept the discounted or minimum cash   
price as payment in full from any       
patient that chooses to pay in cash     
without regard to the patient's         
coverage4  7,d7 ,the payer-specific     
negotiated charges1 expressed as a      
dollar amount and clearly associated    
with the name of the applicable third   
party payer and name of each plan1 that 
apply to each such item or service when 
provided in1 as applicable1 the         
inpatient setting and outpatient        
department setting4 ,if the charges are 
based on an algorithm1 percentage of    
another amount1 or other formula or     
criteria1 the provider or supplier also 

shall disclose such algorithm1          
percentage1 formula1 or criteria as set 
forth in its contract and any other     
terms1 schedules1 exhibits1 data1 or    
other information referenced in any such
 contract as shall be required to       
determine and disclose the negotiated   
charge4  7,e7 ,the de-identified maximum
 and minimum negotiated charges for each
 such item or service1 expressed as a   
non-zero dollar amount4  7,f7 ,any other
 additional information the ,secretary  
may require for the purpose of improving
 the accuracy of1 or enabling consumers 
to easily understand and compare1       
standard charges and prices for an item 
or service1 except information that is  
duplicative of any other reporting      
requirement under this subsection4 ,in  
the case of standard charges and prices 
for an item or service included as part 
of a bundled1 per diem1 episodic1 or    
other similar arrangement1 the          
information described in this           
subparagraph shall be made available as 

determined appropriate by the           
,secretary4  7#c7 ,uniform method and   
format ,not later than ,january #a1     
#bjbg1 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 shall-- 7,a7 include a
 machine-readable spreadsheet format    
containing the information described in 
paragraph 7#b7 for all items and        
services furnished by each provider of  
services and supplier described in      
paragraph 7#a72  7,b7 meet such         
standards as determined appropriate by  
the ,secretary in order to ensure the   
accessibility and usability of such     
information2 and  7,c7 be updated as    
determined appropriate by the           
,secretary1 in consultation with        
stakeholders4  7#d7 ,monitoring         
compliance ,the ,secretary shall1       
through notice and comment rulemaking   
and in consultation with the ,inspector 

,general of the ,department of ,health  
and ,human ,services1 establish a       
process to monitor compliance with this 
subsection4  7#e7 ,enforcement  7,a7 ,in
 general ,in the case that the          
,secretary determines that a provider of
 services or supplier is not in         
compliance with paragraph 7#a7-- 7i7 not
 later than #cj days after such         
determination1 the ,secretary shall     
notify such provider or supplier of such
 determination2  7ii7 upon request of   
the ,secretary1 such provider or        
supplier shall submit to the ,secretary1
 not later than #de days after the date 
of such request1 a corrective action    
plan to comply with such paragraph2 and 
7iii7 if such provider or supplier      
continues to fail to comply with such   
paragraph after the date that is #ij    
days after such notification is sent    
7or1 in the case of such a provider or  
supplier that has submitted a corrective
 action plan described in clause 7ii7 in
 response to a request so described1    

after the date that is #ij days after   
such submission71 the ,secretary may    
impose a civil monetary penalty in an   
amount not to exceed #cjj for each day  
7beginning with the day on which the    
,secretary first determined that such   
provider or supplier was failing to     
comply with such paragraph7 during which
 such failure to comply or failure to   
submit is ongoing4  7,b7 ,increase      
authority ,in applying this paragraph   
with respect to violations occurring in 
#bjbg or a subsequent year1 the         
,secretary may through notice and       
comment rulemaking increase the amount  
of the civil monetary penalty under     
subparagraph 7,a77iii74  7,c7           
,application of certain provisions ,the 
provisions of section #aabh;,a of the   
,social ,security ,act 7other than      
subsections 7a7 and 7b7 of such section7
 shall apply to a civil monetary penalty
 imposed under this paragraph in the    
same manner as such provisions apply to 
a civil monetary penalty imposed under  

subsection 7a7 of such section4  7,d7   
,no authority to waive or reduce penalty
 ,the ,secretary shall not grant or     
extend any waiver1 delay1 tolling1 or   
other mitigation of a civil monetary    
penalty for violation of this           
subsection4  7,e7 ,provision of         
technical assistance ,the ,secretary    
shall1 to the extent practicable1       
provide technical assistance relating to
 compliance with the provisions of this 
subsection to providers of services and 
suppliers requesting such assistance4   
7,f7 ,clarification of nonapplicability 
of other enforcement provisions         
,notwithstanding any other provision of 
this title1 this paragraph shall be the 
sole means of enforcing the provisions  
of this subsection4  7#f7 ,specified    
imaging service defined the term        
specified imaging service means an      
imaging service that is a ,centers for  
,medicare  ,medicaid ,services-specified
 shoppable service 7as described in     
subsection 7e774  7#g7 ,rulemaking ,the 

,secretary shall implement this         
subsection through notice and comment   
rulemaking in accordance with section   
#eec of title #e1 ,united ,states ,code4
  4  #e4 ,ambulatory surgical center    
price transparency requirements ,section
 #bgah of the ,public ,health ,service  
,act 7#db ,u4,s4,c4 #cjj;gg-#ah71 as    
amended by section #d1 is further       
amended by adding at the end the        
following3  7h7 ,ambulatory surgery     
center transparency  7#a7 ,in general   
,beginning ,july #a1 #bjbg1 each        
specified ambulatory surgical center    
shall comply with the price transparency
 requirement described in paragraph     
7#b74  7#b7 ,requirement described  7,a7
 ,in general ,a specified ambulatory    
surgical center1 in accordance with a   
method and format established by the    
,secretary under subparagraph 7,c71     
shall compile and make public 7without  
subscription and free of charge71 for   
each year-- 7i7 one or more lists1 in a 
machine-readable format specified by the

 ,secretary1 of the ambulatory surgical 
center's standard charges 7including the
 information described in subparagraph  
7,b77 for each item and service         
furnished by such surgical center2  7ii7
 information in a consumer-friendly     
format 7as specified by the ,secretary7 
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 included on the list described 
in subsection 7e7 that are furnished by 
such surgical center1 and as many       
additional ambulatory surgical          
center-selected shoppable services 7or  
all such additional services1 if such   
surgical center furnishes fewer than    
#cjj shoppable services7 as may be      
necessary for a combined total of at    
least #cjj shoppable services2 and      
7iii7 with respect to each ,centers for 
,medicare  ,medicaid ,services-specified
 shoppable service 7as described in     

clause 7ii77 that is not furnished by   
the ambulatory surgical center1 an      
indication that such service is not so  
furnished4  7,b7 ,information described 
,for purposes of subparagraph 7,a71 the 
information described in this           
subparagraph is1 with respect to        
standard charges and prices made public 
by a specified ambulatory surgical      
center1 the following3 7i7 ,a           
description of each item or service1    
accompanied by the ,healthcare ,common  
,procedure ,coding ,system code1 the    
national drug code1 or other identifier 
used or approved by the ,centers for    
,medicare  ,medicaid ,services4  7ii7   
,the gross charge1 expressed as a dollar
 amount1 for each such item or service4 
7iii7 ,the discounted cash price1       
expressed as a dollar amount1 for each  
such item or service 7or1 in the case no
 discounted cash price is available for 
an item or service1 the minimum cash    
price accepted by the specified         
ambulatory surgical center from self-pay

 individuals for such item or service   
when provided in such settings for the  
previous three years1 expressed as a    
dollar amount1 as well as1 with respect 
to prices made public pursuant to       
subparagraph 7,a77ii71 a link to a      
consumer-friendly document that clearly 
explains the provider of services or    
supplier's charity care policy74 ,the   
specified ambulatory surgical center    
shall accept the discounted cash price  
as payment in full from any patient that
 chooses to pay in cash without regard  
to the patient's coverage4  7iv7 ,the   
payer-specific negotiated charges1      
expressed as a dollar amount and clearly
 associated with the name of the        
applicable third party payer and name of
 each plan1 that apply to each such item
 or service when provided in1 as        
applicable1 the inpatient setting and   
outpatient department setting4 ,if the  
charges are based on an algorithm1      
percentage of another amount1 or other  
formula or criteria1 the ambulatory     

surgical center also shall disclose such
 algorithm1 percentage1 formula1 or     
criteria as set forth in its contract   
and any other terms1 schedules1         
exhibits1 data1 or other information    
referenced in any such contract as shall
 be required to determine and disclose  
the negotiated charge4  7v7 ,the        
de-identified maximum and minimum       
negotiated charges for each such item or
 service1 expressed as a non-zero dollar
 amount4  7vi7 ,any other additional    
information the ,secretary may require  
for the purpose of improving the        
accuracy of1 or enabling consumers to   
easily understand and compare1 standard 
charges and prices for an item or       
service1 except information that is     
duplicative of any other reporting      
requirement under this subsection4  7,c7
 ,uniform method and format ,not later  
than ,january #a1 #bjbg1 the ,secretary 
shall establish a standard1 uniform     
method and format for specified         
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 shall-- 7i7 in   
the case of such charges made public by 
an ambulatory surgical center1 ensure   
that such charges are made available in 
a machine-readable format2  7ii7 meet   
such standards as determined appropriate
 by the ,secretary in order to ensure   
the accessibility and usability of such 
charges and prices2 and  7iii7 be       
updated as determined appropriate by the
 ,secretary1 in consultation with       
stakeholders4  7#c7 ,no deemed          
compliance ,the availability of a price 
estimator tool shall not be considered  
to deem compliance with or otherwise    
vitiate the requirements of this        
subsection 7aa74 ,furthermore1 the use  
of an estimator tool shall not be used  
for purposes of compliance with any     
provisions in this subsection4  7#d7    

,monitoring compliance ,the ,secretary  
shall1 in consultation with the         
,inspector ,general of the ,department  
of ,health and ,human ,services1        
establish a process to monitor          
compliance with this subsection4 ,such  
process shall ensure that each specified
 ambulatory surgical center's compliance
 with this subsection is reviewed not   
less frequently than once every year4   
7#e7 ,enforcement  7,a7 ,in general ,in 
the case of a specified ambulatory      
surgical center that fails to comply    
with the requirements of this           
subsection-- 7i7 the ,secretary shall   
notify such ambulatory surgical center  
of such failure not later than #cj days 
after the date on which the ,secretary  
determines such failure exists2 and     
7ii7 upon request of the ,secretary1 the
 ambulatory surgical center shall submit
 to the ,secretary1 not later than #de  
days after the date of such request1 a  
corrective action plan to comply with   
such requirements4  7,b7 ,civil monetary

 penalty  7i7 ,in general ,a specified  
ambulatory surgical center that has     
received a notification under           
subparagraph 7,a77i7 and fails to comply
 with the requirements of this          
subsection by the date that is #ij days 
after such notification 7or1 in the case
 of an ambulatory surgical center that  
has submitted a corrective action plan  
described in subparagraph 7,a77ii7 in   
response to a request so described1 by  
the date that is #ij days after such    
submission7 shall be subject to a civil 
monetary penalty of an amount specified 
by the ,secretary for each day          
7beginning with the day on which the    
,secretary first determined that such   
hospital was not complying with such    
requirements7 during which such failure 
is ongoing 7not to exceed #cjj per day74
  7ii7 ,increase authority ,in applying 
this subparagraph with respect to       
violations occurring in #bjbg or a      
subsequent year1 the ,secretary may     
through notice and comment rulemaking   

increase the limitation on the per day  
amount of any penalty applicable to a   
specified ambulatory surgical center    
under clause 7i74  7iii7 ,application of
 certain provisions ,the provisions of  
section #aabh;,a of the ,social         
,security ,act 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   
,no authority to waive or reduce penalty
 ,the ,secretary shall not grant or     
extend any waiver1 delay1 tolling1 or   
other mitigation of a civil monetary    
penalty for violation of this           
subsection4  7#f7 ,provision of         
technical assistance ,the ,secretary    
shall1 to the extent practicable1       
provide technical assistance relating to
 compliance with the provisions of this 
subsection to specified ambulatory      
surgical centers requesting such        

assistance4  7#g7 ,definitions ,for     
purposes of this section3 7,a7          
,discounted cash price ,the term        
discounted cash price means the charge  
that applies to an individual who pays  
cash1 or cash equivalent1 for a item or 
service furnished by an ambulatory      
surgical center4  7,b7 ,gross charge    
,the term gross charge means the charge 
for an individual item or service that  
is reflected on a specified surgical    
center's chargemaster1 absent any       
discounts4  7,c7 ,group health plan2    
group health insurance coverage2        
individual health insurance coverage    
,the terms group health plan1 group     
health insurance coverage1 and          
individual health insurance coverage    
have the meaning given such terms in    
section #bgia of the ,public ,health    
,service ,act4  7,d7 ,payer-specific    
negotiated charge ,the term             
payer-specific negotiated charge means  
the charge that a specified surgical    
center has negotiated with a third party

 payer for an item or service4  7,e7    
,shoppable service ,the term shoppable  
service means a service that can be     
scheduled by a health care consumer in  
advance and includes all ancillary items
 and services customarily furnished as  
part of such service4  7,f7 ,specified  
ambulatory surgical center ,the term    
specified ambulatory surgical center    
means an ambulatory surgical center with
 respect to which a hospital 7or any    
person with an ownership or control     
interest 7as defined in section         
#aabd7;a77#c7 of the ,social ,security  
,act7 in a hospital7 is a person with an
 ownership or control interest 7as so   
defined74  7,g7 ,third party payer ,the 
term third party payer means an entity  
that is1 by statute1 contract1 or       
agreement1 legally responsible for      
payment of a claim for a health care    
item or service4  7#h7 ,rulemaking ,the 
,secretary shall implement this         
subsection through notice and comment   
rulemaking in accordance with section   

#eec of title #e1 ,united ,states ,code4
  4  #f4 ,strengthening health coverage 
transparency requirements  7a7          
,transparency in coverage ,section      
#acaa7;e77#c77;,c7 of the ,patient      
,protection and ,affordable ,care ,act  
7#db ,u4,s4,c4 #ahjca7;e77#c77;,c77 is  
amended-- 7#a7 by striking ,the         
,exchange and inserting the following3  
7i7 ,in general ,the ,exchange  2  7#b7 
in clause 7i71 as inserted by paragraph 
7#a7-- 7,a7 by striking participating   
provider and inserting provider2  7,b7  
by inserting shall include the          
information specified in clause 7ii7 and
 after such information2  7,c7 by       
striking an ,internet website and       
inserting a self-service tool that meets
 the requirements of clause 7iii72 and  
7,d7 by striking and such other and all 
that follows through the period and     
inserting or1 at the option such        
individual1 through a paper or phone    
disclosure 7as selected by such         
individual and provided at no cost to   

such individual7 that meets such        
requirements as the ,secretary may      
specify42 and  7#c7 by adding at the end
 the following new clauses3  7ii7       
,specified information ,for purposes of 
clause 7i71 the information specified in
 this clause is1 with respect to        
benefits available under a health plan  
for an item or service furnished by a   
health care provider1 the following3    
7,i7 ,if such provider is a             
participating provider with respect to  
such item or service1 the in-network    
rate 7as defined in subparagraph 7,f77  
for such item or service4  7,,ii7 ,if   
such provider is not described in       
subclause 7,i71 the maximum allowed     
dollar amount for such item or service4 
7,,iii7 ,the 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 
subclause 7,,ii71 shall be calculated   

using the maximum amount described in   
such subclause74  7,,iv7 ,the amount the
 individual has already accumulated with
 respect to any deductible or out of    
pocket maximum under the plan 7broken   
down1 in the case separate deductibles  
or maximums apply to separate           
individuals enrolled in the plan1 by    
such separate deductibles or maximums1  
in addition to any cumulative deductible
 or maximum74  7,v7 ,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,,vi7 ,any prior             
authorization1 concurrent review1 step  
therapy1 fail first1 or similar         
requirements applicable to coverage of  
such item or service under such plan4   
7iii7 ,self-service tool ,for purposes  
of clause 7i71 a self-service tool      
established by a health plan meets the  

requirements of this clause if such     
tool-- 7,i7 is based on an internet     
website2  7,,ii7 provides for real-time 
responses to requests described in such 
clause2  7,,iii7 is updated in a manner 
such that information provided through  
such tool is timely and accurate2       
7,,iv7 allows such a request to be made 
with respect to an item or service      
furnished by-- 7aa7 a specific provider 
that is a participating provider with   
respect to such item or service2  7bb7  
all providers that are participating    
providers with respect to such plan and 
such item or service2 or  7cc7 a        
provider that is not described in item  
7bb72  7,v7 provides that such a request
 may be made with respect to an item or 
service through use of-- 7aa7 the       
billing code for such item or service2  
or  7bb7 through use of a descriptive   
term for such item or service to produce
 a list of billing code options from    
which the individual selects to indicate
 the subject matter items or services2  

and  7,,vi7 holds a member harmless for 
the amount of any difference in excess  
of the amount of the individual's       
responsibility generated by the         
self-service tool and the amount        
ultimately billed or charged to the     
individual4  4  7b7 ,disclosure of      
additional information ,section         
#acaa7;e77#c7 of the ,patient           
,protection and ,affordable ,care ,act  
7#db ,u4,s4,c4 #ahjca7;e77#c77 is       
amended by adding at the end the        
following new subparagraphs3  7,e7 ,rate
 and payment information  7i7 ,in       
general ,not later than ,january #a1    
#bjbg1 and every month thereafter1 each 
health plan shall submit to the         
,exchange1 the ,secretary1 the ,state   
insurance commissioner1 and make        
available to the public1 the rate and   
payment information described in clause 
7ii7 in accordance with clause 7iii74   
7ii7 ,rate and payment information      
described ,for purposes of clause 7i71  
the rate and payment information        

described in this clause is1 with       
respect to a health plan1 the following3
 7,i7 ,with respect to each item or     
service for which benefits are available
 under such plan 7expressed as a dollar 
amount71 including prescription drugs1  
identified by ,,cpt1 ,,hcpcs1 ,,drg1    
,,ndc1 or other applicable nationally   
recognized identifier1 including any    
applicable code modifiers1 and          
accompanied by a brief description of   
the item or service1 the in-network rate
 in effect as of the date of the        
submission of such information with each
 provider 7identified by national       
provider identifier7 that is a          
participating provider with respect to  
such item or service1 other than such a 
rate in effect with a provider-- 7aa7   
that has submitted no claims2 and  7bb7 
expects to receive no claims in the then
 applicable calendar year for such item 
or service to such plan4  7,,ii7 ,with  
respect to each drug 7identified by     
,national ,drug ,code1 ,j-code1 or other

 commonly recognized billing code used  
for drugs7 for which benefits are       
available under such plan3 7aa7 ,the    
in-network rate 7expressed as a dollar  
amount71 including the individual and   
total amounts for any bundled rates1 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 drug4  7bb7 ,the historical net    
price paid by such plan 7net of rebates1
 discounts1 and price concessions7      
7expressed as a dollar amount7 for such 
drug dispensed or administered during   
the #ij-;day period beginning #ahj days 
before such date of submission to each  
provider that was a participating       
provider with respect to such drug1     
broken down by each such provider       
7identified by national provider        
identifier71 other than such an amount  
paid to a provider that has submitted no
 claims for such drug to such plan4     
7,,iii7 ,with respect to each item or   

service for which benefits are available
 under such plan 7expressed as a dollar 
amount71 identified by ,,cpt1 ,,drg1    
,,hcpcs1 ,,ndc1 or other applicable     
nationally recognized identifier1       
including any applicable code modifiers1
 and accompanied by a brief description 
of the item or service1 the amount      
billed or charged by the provider1 and  
the amount allowed by the plan1 for each
 such item or service furnished during  
the #ij-;day period beginning #ahj days 
before such date of submission by each  
provider that was not a participating   
provider with respect to such item or   
service1 broken down by each such       
provider 7identified by national        
provider identifier71 other than items  
and services with respect to which no   
claims for such item or service were    
submitted to such plan during such      
period4  7iii7 ,manner of submission    
,rate and payment information required  
to be submitted and made available under
 this subparagraph shall be so submitted

 and so made available as follows3 7,i7 
,information shall be contained in #c   
separate machine-readable files         
corresponding to the information        
described in each of subclauses 7,i7    
through 7,,iii7 of clause 7ii7 that meet
 such requirements as specified by the  
,secretary through rulemaking1 in       
consultation with the ,secretaries of   
,labor and the ,treasury to apply       
comparable requirements to group health 
plans and to entities providing benefit 
management or other third-party         
administration services on a contractual
 basis with a group health plan4  7,,ii7
 ,requirements specified by the         
,secretary through rulemaking shall     
ensure that3 7aa7 ,such files are       
limited to an appropriate size1 are made
 available in a widely available format 
that allows for information contained in
 such files to be compared across health
 plans1 and are accessible to           
individuals at no cost and without the  
need to establish a user account or     

provider other credentials4  7bb7 ,the  
rates1 amounts1 and prices to be        
disclosed include contractual terms     
containing calculation formulae1 pricing
 methodologies1 and other information   
necessary to determine the dollar value 
of reimbursement4  7cc7 ,each such file 
includes each of the following data     
elements3 7,,aa7 ,a numerical identifier
 for the group health plan and_/or      
health insurance issuer 7such as a      
,health ,insurance ,oversight ,system   
identifier74 7,,bb7 ,a plain-language   
description of the item or service      
7including1 for drugs1 the proprietary  
and nonproprietary name assigned74      
7,,cc7 ,the billing code1 including any 
applicable modifiers1 associated with   
such item or service1 including the     
,healthcare ,common ,procedure ,coding  
,system code1 diagnosis-related group1  
national drug code1 or other commonly   
recognized code set4 7,,dd7 ,the place  
of service code4 7,,ee7 ,the ,national  
,provider ,identifier or provider ,tax  

,identification ,number4  7,,iii7 ,the  
rate and payment information disclosed  
under subclauses 7,i7 through 7,,iii7 of
 clause 7ii7 shall be separately        
delineated for each item or service1    
regardless of whether such item or      
service is reimbursed as a part of a    
bundle1 episode1 or other grouping of   
items and services4  7,,iv7 ,an officer 
or executive of competent authority     
shall attest to the accuracy and        
completeness of information submitted   
and made available under this           
subparagraph4 ,such attestation shall be
 subject to enforcement under           
subparagraph 7,h7 and1 where applicable1
 shall be deemed material to payments   
from the ,federal ,government received  
by the group health plan or health      
insurance issuer4  7,v7 ,regulations    
promulgated pursuant to this section    
shall provide that3 7aa7 ,the ,secretary
 shall audit the three machine-readable 
files required by subparagraph 7,e77ii7 
posted by no fewer than #bj group health

 plans or health insurance issuers4     
7bb7 ,the ,secretary of ,labor shall    
audit the three machine-readable files  
required by subparagraph 7,e77ii7 posted
 by no fewer than #bjj group health     
plans or service providers furnishing   
third-party administrator services to a 
group health plan4  7cc7 ,findings1     
conclusions1 and enforcement actions    
taken based on audits of the            
machine-readable files shall be reported
 annually to ,congress no later than    
,july #a of the calendar year during    
which the files were audited4 ,such     
report to ,congress shall be accessible 
to the public4  7iv7 ,user guide ,each  
health plan shall make available to the 
public instructions written in plain    
language explaining how individuals may 
search for information described in     
clause 7ii7 in files submitted in       
accordance with clause 7iii74  7,f7     
,definitions ,in this paragraph3 7i7    
,participating provider ,the term       
participating provider has the meaning  

given such term in section #bgii;,a-#a  
of the ,public ,health ,service ,act4   
7ii7 ,in-network rate ,the term         
in-network rate means1 with respect to a
 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 in effect between such  
plan and such provider for such item or 
service4 ,if the rate is based on an    
algorithm1 percentage of another amount1
 or other formula or criteria1 the      
health plan also shall disclose such    
algorithm1 percentage1 formula1 or      
criteria as set forth in its contract   
and any other terms1 schedules1         
exhibits1 data1 or other information    
referenced in any such contract as shall
 be required to determine and disclose  
the negotiated rate4  7,g7              
,applicability to accountable care      
organizations ,an applicable ,,aco      
participating in the ,medicare ,shared  
,savings ,program1 as defined in        

,section #ahii of the ,social ,security 
,act 7#db ,u4,s4,c4 #acie;jjj71 shall be
 subject to the requirements of this    
paragraph as if such applicable ,,aco is
 a group health plan or health insurance
 issuer4  7,h7 ,enforcement  7i7 ,in    
general ,each year1 the ,secretary shall
 audit the three machine-readable files 
required by subparagraph 7,e77ii7 posted
 by no fewer than #bj group health plans
 or health insurance issuers4  7ii7     
,notification and request for corrective
 action ,in the case of a health plan   
that fails to comply with the           
requirements of this subsection1 not    
later than #cj days after the date on   
which the ,secretary determines such    
failure exists1 the ,secretary shall    
submit to such health plan a            
notification of such determination1     
which shall include a request for a     
corrective action plan to comply with   
such requirements4  7iii7 ,civil        
monetary penalty ,a health plan that has
 received a request for a corrective    

action plan under clause 7ii7 and fails 
to comply with the requirements of this 
subsection by the date that is #ij days 
after such request is made 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 laboratory was failing to     
comply with such paragraph7 during which
 such failure was ongoing4 ,such amount 
shall not exceed #cjj per member per day
 or #aj1jjj1jjj1 whichever is lesser4   
7,i7 ,rulemaking ,the ,secretary shall  
implement subparagraphs 7,e7 through    
7,h7 through notice and comment         
rulemaking in accordance with section   
#eec of title #e1 ,united ,states ,code4
  4  7c7 ,effective date  7#a7 ,in      
general ,the amendments made by         
subsections 7a7 and 7b7 shall apply     
beginning ,january #a1 #bjbf4  7#b7     
,continued applicability of rules for   
previous years ,nothing in the          
amendments made by this section 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 #gbaeh7 before   
,january #a1 #bjbf4  #g4 ,increasing    
group health plan access to health data 
7a7 ,group health plan access to        
information  7#a7 ,in general ,paragraph
 7#b7 of section #djh7;b7 of the        
,employee ,retirement ,income ,security 
,act of #aigd 7#bi ,u4,s4,c4 #aajh7;b77 
is amended by adding at the end the     
following new subparagraphs3  7,c7 ,no  
contract or arrangement for services1   
and no extension or renewal of such     
contract or arrangement1 between a group
 health plan 7as that term is defined in
 section #gcc7;a7 of this title7 and    
party in interest1 including a health   
care provider 7which for purposes of    
this subparagraph1 includes a health    
care facility71 network or association  

of providers1 service provider offering 
access to a network of providers1       
third-party administrator1 or pharmacy  
benefit manager 7collectively referred  
to as ,covered ,service ,providers71 is 
reasonable within the meaning of this   
paragraph unless such contract or       
arrangement-- 7i7 allows the responsible
 plan fiduciary 7as that term is defined
 in subparagraph 7,b77ii77,i77ee77      
access to all claims and encounter      
information or data1 and any            
documentation supporting claim payments1
 including1 but not limited to1 medical 
records and policy documents1 or        
information or data described in section
 #gbd7;a77#a77;,b7 to-- 7,i7 enable such
 entity to comply with the terms of the 
plan and any applicable law2 and  7,,ii7
 determine the accuracy or              
reasonableness of payment2 and  7ii7    
does not-- 7,i7 unreasonably limit or   
delay access1 as determined by the      
,secretary but in any event not longer  
than #ae days1 to such information or   

data2  7,,ii7 limit the volume of claims
 and encounter information or data that 
the group health plan1 the plan sponsor1
 the plan administrator1 or a business  
associate of such plan may access during
 an audit or pursuant to any request for
 such information or data2  7,,iii7     
limit the disclosure of pricing terms   
for value-based payment arrangements or 
capitated payment arrangements1         
including-- 7aa7 payment calculations   
and formulas2  7bb7 quality measures2   
7cc7 contract terms2  7dd7 payment      
amounts2  7ee7 measurement periods for  
all incentives2 and  7ff7 other payment 
methodologies used by an entity1        
including a health care provider        
7including a health care facility71     
network or association of providers1    
service provider offering access to a   
network of providers1 third-party       
administrator1 or pharmacy benefit      
manager2  7,,iv7 limit the disclosure of
 overpayments and overpayment recovery  
terms2  7,v7 limit the right of the     

group health plan1 the plan sponsor1 or 
the plan administrator of such plan to  
select an auditor or define audit scope 
or frequency2  7,,vi7 otherwise limit or
 unduly delay the group health plan1 the
 plan sponsor1 the plan administrator1  
or a business associate of such plan    
from accessing claims and encounter     
information or data in a daily batch2   
7,,vii7 limit the disclosure of fees    
charged to the group health plan related
 to plan administration and claims      
processing1 including renegotiation     
fees1 access fees1 repricing fees1 or   
enhanced review fees2  7,,viii7 limit   
the right of the group health plan1 the 
plan sponsor1 or the plan administrator 
to request action on any suspect claim  
payments2 or  7,,ix7 limit public       
disclosure of de-identified or aggregate
 information4  7,d7 7i7 ,covered        
,service ,providers shall provide       
information or data under this paragraph
 in a manner consistent with the privacy
 and security regulations promulgated   

under the ,health ,insurance            
,portability and ,accountability ,act   
7referred to in this subparagraph as    
,,hipaa74  7ii7 ,a group health plan    
that receives a disclosure from a party 
in interest pursuant to subparagraph    
7,b7 or 7,c7 shall comply with the      
privacy and security regulations        
promulgated under ,,hipaa4  7iii7       
,nothing in this subparagraph shall be  
construed to modify the requirements for
 the creation1 receipt1 maintenance1 or 
transmission of protected health        
information under the ,,hipaa privacy   
regulation 7as defined in section       
#aahj7;b77#c7 of the ,social ,security  
,act7 as they apply directly or         
indirectly to an entity pursuant to this
 paragraph4  7iv7 ,this subparagraph    
shall not be read to abridge or limit   
the disclosure requirements under this  
paragraph or to impose additional       
privacy or security requirements on     
,covered ,service ,providers or plan    
sponsors4  7,e7 ,a group health plan    

receiving information or data under this
 paragraph may disclose such information
 only in a manner that is consistent    
with the ,health ,insurance ,portability
 and ,accountability ,act 7,,hipaa7 and 
the privacy and security regulations    
promulgated thereunder1 regardless of   
their direct or indirect applicability  
to the plan or any entities that could  
be or are business associates4  7,f7    
,information made available under this  
section shall conform to the following  
standards3 7i7 ,all claims from a       
healthcare provider shall be made to the
 group health plan in accordance with   
transaction standards adopted by        
regulation under ,,hipaa1 as follows3   
7,i7 ,institutional1 professional1 and  
dental claims shall be in ,,asc ,x#ab,n 
#hcg format or any subsequent standard4 
7,,ii7 ,pharmacy claims shall be in the 
,national ,council for ,prescription    
,drug ,programs 7,,ncpdp7 format or any 
subsequent standard4  7,,iii7 ,the files
 shall be unmodified copies of the files

 sent from the provider4 ,in the event  
that paper claims are sent by the       
provider1 they shall be converted to the
 appropriate standard electronic format4
 ,files shall be accessible to the plan 
at no cost to the group health plan4    
7ii7 ,all claim payment 7or ,,eft1      
electronic funds transfer7 and          
electronic remittance advice 7,,era7    
notices sent by a ,covered ,service     
,provider shall be made available to the
 group health plan as ,,asc ,x#ab,n #hce
 files in accordance with standards     
adopted by regulation under ,,hipaa4    
,the files shall be unmodified copies of
 the files sent by the ,covered ,service
 ,provider to the healthcare provider4  
,files shall be accessible at no cost to
 the group health plan4  7iii7 ,the     
contractual terms containing calculation
 formulae1 pricing methodologies1 and   
other information used to determine the 
dollar value of reimbursement4  7iv7    
,all non-claim costs shall be itemized  
and made available to the group health  

plan in real time through a web-based   
portal1 through an ,,api1 and through a 
downloadable ,,csv file4  7,g7 ,the     
,secretary shall implement subparagraphs
 7,c7 through 7,f7 through notice and   
comment rulemaking in accordance with   
section #eec of title #e1 ,united       
,states ,code4  4  7#b7 ,civil          
enforcement ,subsection 7c7 of section  
#ejb of such ,act 7#bi ,u4,s4,c4 #aacb7 
is amended by adding at the end the     
following new paragraph3  7#ac7 ,in the 
case of an agreement between a group    
health plan 7as defined in section      
#gcc7;a771 the plan sponsor of such plan
 7as defined in section #c7af77;,b771 or
 the plan administrator of such plan 7as
 defined in section #c7af77;,a77 and a  
health care provider 7which1 for        
purposes of this paragraph1 includes a  
health care facility71 network or       
association of providers1 service       
provider offering access to a network or
 association of providers1 third-party  
administrator1 or pharmacy benefit      

manager1 that violates the provisions of
 section #gbd1 the ,secretary may assess
 a civil penalty against such provider1 
network or association1 service provider
 offering access to a network or        
association of providers1 third-party   
administrator1 pharmacy benefit manager1
 or other service provider in the amount
 of #aj1jjj for each day during which   
such violation continues4 ,such penalty 
shall be in addition to other penalties 
as may be prescribed by law4  4  7#c7   
,existing provisions void ,section #daj 
of such ,act 7#bi ,u4,s4,c4 #aaaj7 is   
amended by adding at the end the        
following3  7c7 ,any provision in an    
agreement or instrument shall be void as
 against public policy if such          
provision-- 7#a7 unduly delays or limits
 a group health plan 7as defined in     
section #gcc7;a771 the plan sponsor of  
such plan 7as defined in section        
#c7af77;,b771 or the plan administrator 
of such plan 7as defined in section     
#c7af77;,a77 from accessing the claims  

and encounter information or data       
described in section #gbd7;a77#a77;,b72 
or  7#b7 violates the requirements of   
section #djh7;b77#b77;,c74  4  7#d7     
,technical amendment ,clause 7i7 of     
section #djh7;b77#b77;,b7 of such ,act  
is amended by striking this clause and  
inserting this paragraph4  7b7 ,updated 
attestation for price and quality       
information ,section #gbd7;a77#c7 of the
 ,employee ,retirement ,income ,security
 ,act of #aigd 7#bi ,u4,s4,c4           
#aahem7a77#c77 is amended to read as    
follows3  7#c7 ,attestation  7,a7 ,in   
general ,subject to subparagraph 7,c71 a
 group health plan or health insurance  
issuer offering group health insurance  
coverage shall annually submit to the   
,secretary an attestation that such plan
 or issuer of such coverage is in       
compliance with the requirements of this
 subsection4 ,such attestation shall    
also include a statement verifying      
that-- 7i7 the information or data      
described under subparagraphs 7,a7 and  

7,b7 of paragraph 7#a7 is available upon
 request and provided to the group      
health plan1 the plan sponsor1 the plan 
administrator1 or the business associate
 of such plan1 or the issuer in a timely
 manner2 and  7ii7 there are no terms in
 the agreement under such paragraph 7#a7
 that directly or indirectly restrict or
 unduly delay a group health plan1 the  
plan sponsor1 the plan administrator1 a 
business associate of such plan1 or the 
issuer from auditing1 reviewing1 or     
otherwise accessing such information4   
7,b7 ,limitation on submission ,subject 
to clause 7ii71 a group health plan or  
issuer offering group health insurance  
coverage may not enter into an agreement
 with a third-party administrator or    
other service provider to submit the    
attestation required under subparagraph 
7,a74  7,c7 ,exception ,in the case of a
 group health plan or issuer offering   
group health insurance coverage that is 
unable to obtain the information or data
 needed to submit the attestation       

required under subparagraph 7,a71 such  
plan or issuer may submit a written     
statement in lieu of such attestation   
that includes-- 7i7 an explanation of   
why such plan or issuer was unsuccessful
 in obtaining such information or data1 
including whether such plan1 the plan   
sponsor1 or the plan administrator or   
issuer was limited or prevented from    
auditing1 reviewing1 or otherwise       
accessing such information or data2     
7ii7 a description of the efforts made  
by the group health plan1 the plan      
sponsor1 or the plan administrator to   
remove any gag clause provisions from   
the agreement under paragraph 7#a72 and 
7iii7 a description of any response by  
the third-party administrator or other  
service provider with respect to efforts
 to comply with the attestation         
requirement under subparagraph 7,a71    
including the name of the third-party   
administrator or other service provider4
  4  7c7 ,effective date ,the amendments
 made by subsections 7a7 and 7b7 shall  

apply with respect to a plan beginning  
with the first plan year that begins on 
or after the date that is #a year after 
the date of enactment of this ,act4  #h4
 ,oversight of administrative service   
providers  7a7 ,,erisa amendments  7#a7 
,in general ,subpart ,b of part #g of   
subtitle ,b of the ,employee ,retirement
 ,income ,security ,act of #aigd 7#bi   
,u4,s4,c4 #ajba et seq47 is amended by  
adding at the end the following3  #gbf4 
,oversight of administrative service    
providers  7a7 ,in general ,for plan    
years beginning on or after the date    
that is #b years after the date of      
enactment of this section1 no agreement 
between a group health plan 7as defined 
in section #gcc7;a771 the plan sponsor  
of such plan 7as defined in section     
#c7af77;,b771 the plan administrator of 
such plan 7as defined in section        
#c7af77;,a771 or a business associate of
 such plan 7as defined in section       
#afj4ajc of title #de1 ,code of ,federal
 ,regulations71 7or health insurance    

issuer offering group health insurance  
coverage in connection with such a      
plan71 and a health care provider1      
network or association of providers1    
third-party administrator1 service      
provider offering access to a network of
 providers1 pharmacy benefit managers1  
or any other third party 7each referred 
to as a health plan service provider7 is
 permissible if such agreement limits   
7or delays beyond the applicable        
reporting period described in subsection
 7b77#a77 the disclosure of information 
to group health plans in such a manner  
that prevents such plan1 issuer1 or     
entity from providing the information   
described in subsection 7b74  7b7       
,required disclosures  7#a7 ,contents   
and frequency ,with respect to plan     
years beginning on or after the date    
that is #b years after the date of      
enactment of this section1 not less     
frequently than quarterly1 a health plan
 service provider shall provide to the  
group health plan or health insurance   

issuer the following information at no  
cost to the group health plan or health 
insurance issuer3 7,a7 ,the information 
described in section #gbd7;a77#a77;,b74 
7,b7 ,any contractual and subcontractual
 calculation methodologies1 pricing or  
fee schedules1 or other formulae used to
 determine reimbursement amounts to     
providers and subcontractors1 including 
methodologies1 schedules1 fee           
structures1 and any applied adjustments 
or modifiers1 with such information     
provided in a manner sufficiently       
detailed to enable the group health plan
 or health insurance issuer to          
accurately assess1 verify1 and ensure   
compliance with the terms of any        
contractual and subcontractual agreement
 governing the reimbursement amounts4   
7,c7 ,the total amount received or      
expected to be received by the health   
plan service provider or its            
subcontractors in provider or supplier  
rebates1 fees1 alternative discounts1   
and all other remuneration including    

amounts held in escrow or variance      
accounts that has been paid or is to be 
paid for claims incurred and            
administrative services including data  
sales or network payments4  7,d7 ,the   
total amount paid or expected to be paid
 by the health plan service provider or 
to subcontractors in rebates1 fees1     
contractual arrangements1 and all other 
remuneration that has been paid or is   
expected to be paid for administrative  
and other services4  7,e7 ,all payment  
data and reconciliation information     
related to alternative compensation     
arrangements including accountable care 
organizations1 value-based programs1    
shared savings programs1 incentive      
compensation1 bundled payments1         
capitation arrangements1 performance    
payments1 and any other reimbursement or
 payment models1 where the group health 
plan or health insurance issuer paid    
fees1 incurred obligations1 or made     
payments in connection with the group   
health plan related to such             

arrangements4  7#b7 ,privacy            
requirements  7,a7 ,in general ,health  
plan service providers shall provide the
 information or data under paragraph    
7#a7 consistent with the privacy1       
security1 and breach notification       
regulations at parts #afj and #afd of   
title #de1 ,code of ,federal            
,regulations1 promulgated under subtitle
 ,f of the ,health ,insurance           
,portability and ,accountability ,act of
 #aiif1 subtitle ,d of the ,health      
,information ,technology for ,clinical  
,health ,act of #bjji1 and section #aahj
 of the ,social ,security ,act1 and     
shall restrict the use and disclosure of
 such information according to such     
privacy1 security1 and breach           
notification regulations4 ,an entity    
that receives a disclosure from a party 
in interest pursuant to subparagraph    
7,b7 or 7,c7 shall comply with the      
privacy and security regulations        
promulgated under ,,hipaa4  7,b7        
,restrictions ,a group health plan shall

 comply with section #afd4ejd7;f7 of    
title #de1 ,code of ,federal            
,regulations 7or a successor            
regulation71 and a plan sponsor shall   
act in accordance with the terms of the 
agreement described in such section4    
7,c7 ,rule of construction ,nothing in  
this section shall be construed to      
modify the requirements for the         
creation1 receipt1 maintenance1 or      
transmission of protected health        
information under the ,,hipaa privacy   
regulations 7#de ,c4,f4,r4 parts #afj   
and #afd1 subparts ,a and ,e74  7#c7    
,disclosure and redisclosure  7,a7 ,in  
general ,a group health plan receiving  
information under paragraph 7#a7 may    
disclose such information only-- 7i7 to 
the entity from which the information   
was received or to that entity's        
business associates or to the group     
health plan's business associates as    
defined in section #afj4ajc of title    
#de1 ,code of ,federal ,regulations 7or 
successor regulations72 or  7ii7 as     

permitted by the ,,hipaa ,privacy ,rule 
7#de ,c4,f4,r4 parts #afj and #afd1     
subparts ,a and ,e74  7,b7 ,availability
 of information ,to the extent the      
information required by this subsection 
is made available to the health         
insurance issuer offering group health  
insurance in connection with a group    
health plan1 the health insurance issuer
 shall make such information available1 
at the same time1 in the same format1   
and at no cost1 to the group health     
plan4  7,c7 ,failure to provide ,the    
obligation to provide information       
pursuant to this subsection shall exist 
notwithstanding the presence of any     
formal data-sharing agreement between   
the parties4 ,failure to provide the    
required information as specified shall 
constitute a violation of this ,act and 
the ,secretary shall initiate           
enforcement action under section #ejb   
within #ij days of becoming aware of a  
violation of this section1 except that  
nothing in this section shall be        

construed to limit the ,secretary's     
existing authority under the ,act4  7#d7
 ,data format standards ,all data and   
information provided pursuant to this   
subsection shall comply with the        
following standards3 7,a7 ,all claims   
from a healthcare provider shall be made
 to the group health plan in accordance 
with transactions standards adopted     
under ,,hipaa1 as follows3 7i7          
,institutional1 professional1 and dental
 claims and adjustments to these claims 
shall be in ,,asc ,x#ab,n #hcg format1  
as transmitted by the provider1 or1 in  
the case of paper claims1 converted to  
the ,,asc ,x#ab,n #hcg electronic       
format4  7ii7 ,prescription drug claims 
shall be in the ,national ,council for  
,prescription ,drug ,programs 7,,ncpdp7 
format1 as transmitted by the provider1 
or in the case of paper claims1         
converted to the ,,ncpdp electronic     
format4  7iii7 ,such data shall be      
provided at no cost to the group health 
plan4  7,b7 ,all claim payment 7or      

,,eft1 electronic funds transfer7 and   
electronic remittance advice 7,,era7    
information sent by a health plan       
service provider shall be provided to   
the group health plan or health         
insurance issuer in the ,,asc ,x#ab,n   
#hce format in accordance with          
transaction standards adopted under     
,,hipaa1 unmodified from the form in    
which it was transmitted to the         
healthcare provider4 ,such information  
shall be provided at no cost to the     
group health plan or health insurance   
issuer4  7,c7 ,the ,secretary may modify
 the standards set forth in this        
paragraph as necessary to align with any
 changes adopted by the ,secretary of   
,health and ,human ,services pursuant to
 the authority provided under section   
#aagc of the ,social ,security ,act 7#db
 ,u4,s4,c4 #acbj;d-#b74  7c7 ,prohibited
 contractual provisions ,any provision  
in an agreement between a group health  
plan1 the plan sponsor1 the plan        
administrator1 or a business associate  

of such plan or a health insurance      
issuer and a health plan service        
provider that unduly delays or limits a 
group health plan's or health insurance 
issuer's access to information described
 in this section or that restricts the  
format or timing of the provision of    
such information in a manner that is    
inconsistent with the requirements of   
this section shall be prohibited and1 if
 a group health plan or health insurance
 issuer enters into such agreement1     
shall be deemed void as against public  
policy4  7d7 ,penalties for             
non-,compliance ,any failure by a health
 plan service provider to comply with   
the requirements of this section shall  
result in the imposition of a civil     
penalty of #ajj1jjj for each day the    
violation continues1 in addition to any 
other penalties prescribed by law4  7e7 
,regulations ,the ,secretary shall      
implement this section through notice   
and comment rulemaking in accordance    
with section #eec of title #e1 ,united  

,states ,code4  4  7#b7 ,penalty  7,a7  
,in general ,section #ejb7;a7 of the    
,employee ,retirement ,income ,security 
,act of #aigd 7#bi ,u4,s4,c4 #aacb7;a77 
is amended by adding at the end the     
following new paragraph3  7#ad7 ,the    
,secretary may assess a civil penalty   
against any person of #ajj1jjj per day  
for each violation by any person of     
section #gbf4  4  7,b7 ,technical       
amendment ,paragraph 7#f7 of section    
#ejb7;a7 of the ,employee ,retirement   
,income ,security ,act of #aigd 7#bi    
,u4,s4,c4 #aacb7;a77 is amended by      
striking or 7#i7 and inserting it with  
the phrase 7#i71 7#ac71 or 7#ad74  7b7  
,,phsa amendments  7#a7 ,in general     
,part ,d of title ,,xxvii of the ,public
 ,health ,service ,act 7#db ,u4,s4,c4   
#cjj;gg-#aaa et seq47 is amended by     
adding at the end the following3        
#bgii;,a-#aa4 ,oversight of             
administrative service providers  7a7   
,in general ,for plan years beginning on
 or after the date that is #a year after

 the date of enactment of this section1 
no agreement between a group health plan
 that is a self-funded1 non-,federal    
governmental plan1 as defined in section
 #bgia7;d77#h77;,c7 7#db ,u4,s4,c4      
#cjj;gg-#ia7;d77#h77;,c771 and a health 
care provider1 network or association of
 providers1 third-party administrator1  
service provider offering access to a   
network of providers1 pharmacy benefit  
managers1 or any other third party 7each
 referred to in this section as a health
 plan service provider7 is permissible  
if such agreement limits 7or delays     
beyond the applicable reporting period  
described in subsection 7b77#a77 the    
disclosure of information to group      
health plans in such a manner that      
prevents such plan1 issuer1 or entity   
from providing the information described
 in subsection 7b74  7b7 ,required      
disclosures  7#a7 ,contents and         
frequency ,with respect to plan years   
beginning on or after the date that is  
#a year after the date of enactment of  

this section1 not less frequently than  
quarterly1 a health plan service        
provider shall provide to the group     
health plan that is a self-funded1      
non-,federal governmental plan the      
following information at no cost to the 
plan3 7,a7 ,the information described in
 section #bgii;,a-#i7;a77#a77;,b7 7#db  
,u4,s4,c4 #cjj;gg-#aai7;a77#a77;,b774   
7,b7 ,any contractual and subcontractual
 calculation methodologies1 pricing or  
fee schedules1 or other formulae used to
 determine reimbursement amounts to     
providers and subcontractors1 including 
methodologies1 schedules1 fee           
structures1 and any applied adjustments 
or modifiers1 with such information     
provided in a manner sufficiently       
detailed to enable the group health plan
 to accurately assess1 verify1 and      
ensure compliance with the terms of any 
contractual and subcontractual agreement
 governing the reimbursement amounts4   
7,c7 ,the total amount received or      
expected to be received by the health   

plan service provider or its            
subcontractors in provider or supplier  
rebates1 fees1 alternative discounts1   
and all other remuneration including    
amounts held in escrow or variance      
accounts that has been paid or is to be 
paid for claims incurred and            
administrative services including data  
sales or network payments4  7,d7 ,the   
total amount paid or expected to be paid
 by the health plan service provider or 
to subcontractors in rebates1 fees1     
contractual arrangements1 and all other 
remuneration that has been paid or is   
expected to be paid for administrative  
and other services4  7,e7 ,all payment  
data and reconciliation information     
related to alternative compensation     
arrangements including accountable care 
organizations1 value-based programs1    
shared savings programs1 incentive      
compensation1 bundled payments1         
capitation arrangements1 performance    
payments1 and any other reimbursement or
 payment models1 where the group health 

plan paid fees1 incurred obligations1 or
 made payments in connection with the   
group health plan related to such       
arrangements4  7#b7 ,privacy            
requirements  7,a7 ,in general ,health  
plan service providers shall provide the
 information or data under paragraph    
7#a7 consistent with the privacy1       
security1 and breach notification       
regulations at parts #afj and #afd of   
title #de1 ,code of ,federal            
,regulations1 promulgated under subtitle
 ,f of the ,health ,insurance           
,portability and ,accountability ,act of
 #aiif1 subtitle ,d of the ,health      
,information ,technology for ,clinical  
,health ,act of #bjji1 and section #aahj
 of the ,social ,security ,act1 and     
shall restrict the use and disclosure of
 such information according to such     
privacy1 security1 and breach           
notification regulations4 ,an entity    
that receives a disclosure from a party 
in interest pursuant to subparagraph    
7,b7 or 7,c7 shall comply with the      

privacy and security regulations        
promulgated under ,,hipaa4  7,b7        
,restrictions ,a group health plan that 
is a self-funded1 non-,federal          
governmental plan shall comply with     
section #afd4ejd7;f7 of title #de1 ,code
 of ,federal ,regulations 7or a         
successor regulation71 and a plan       
sponsor shall act in accordance with the
 terms of the agreement described in    
such section4  7,c7 ,rule of            
construction ,nothing in this section   
shall be construed to modify the        
requirements for the creation1 receipt1 
maintenance1 or transmission of         
protected health information under the  
,,hipaa privacy regulations 7#de        
,c4,f4,r4 parts #afj and #afd1 subparts 
,a and ,e74  7#c7 ,disclosure and       
redisclosure  7,a7 ,in general ,a group 
health plan that is a self-funded1      
non-,federal governmental plan receiving
 information under paragraph 7#a7 may   
disclose such information only-- 7i7 to 
the entity from which the information   

was received or to that entity's        
business associates as defined in       
section #afj4ajc of title #de1 ,code of 
,federal ,regulations 7or successor     
regulations72 or  7ii7 as permitted by  
the ,,hipaa ,privacy ,rule 7#de         
,c4,f4,r4 parts #afj and #afd1 subparts 
,a and ,e74  7,b7 ,rule of construction 
,nothing in this section shall be       
construed to prevent a group health plan
 that is a self-funded1 non-,federal    
governmental plan1 or a health plan     
service provider providing services with
 respect to such a plan1 from placing   
reasonable restrictions on the public   
disclosure of the information described 
in paragraph 7#a71 except that such plan
 or entity may not restrict disclosure  
of such information to the ,department  
of ,health and ,human ,services1 the    
,department of ,labor1 the ,department  
of the ,treasury1 or the ,comptroller   
,general of the ,united ,states4  7,c7  
,failure to provide ,the obligation to  
provide information pursuant to this    

subsection shall exist notwithstanding  
the presence of any formal data-sharing 
agreement between the parties4 ,failure 
to provide the required information as  
specified shall constitute a violation  
of this ,act and the ,secretary shall   
initiate enforcement action under       
section #bgbc7;b7 7#db ,u4,s4,c4        
#cjj;gg-#bb7;b77 within #ij days of     
becoming aware of a violation of this   
section1 except that nothing in this    
section shall be construed to limit the 
,secretary's existing authority under   
this ,act4  7#d7 ,data format standards 
,all data and information provided      
pursuant to this subsection shall comply
 with the following standards3 7,a7 ,all
 claims from a healthcare provider shall
 be made to the group health plan in    
accordance with standards adopted under 
,,hipaa at section #afb4aaja of title   
#de1 ,code of ,federal ,regulations1 as 
follows3 7i7 ,institutional1            
professional1 and dental claims and     
adjustments to these claims shall be    

provided to the group health plan that  
is a self-funded1 non-,federal          
governmental plan in the ,,asc ,x#ab,n  
#hcg format4  7ii7 ,prescription drug   
claims shall be in the ,national        
,council for ,prescription ,drug        
,programs 7,,ncpdp7 format4  7iii7 ,the 
files shall be unmodified copies of the 
files sent from the provider4 ,in the   
event that paper claims are sent by the 
provider1 they shall be converted to the
 appropriate standard electronic format4
 ,such data shall be provided at no cost
 to the group health plan4  7,b7 ,all   
claim payment 7or ,,eft1 electronic     
funds transfer7 and electronic          
remittance advice 7,,era7 information   
sent by a health plan service provider  
shall be provided to the group health   
plan or health insurance issuer in the  
,,asc ,x#ab,n #hce format1 in accordance
 with standards adopted under ,,hipaa at
 section #afb4afjb of title #de1 ,code  
of ,federal ,regulations1 unmodified    
from the form in which it was           

transmitted to the healthcare provider4 
,such information shall be provided at  
no cost to the group health plan4  7,c7 
,the ,secretary may modify the standards
 set forth in this paragraph as         
necessary to align with any changes     
adopted by the ,secretary pursuant to   
the authority provided under section    
#aagc of the ,social ,security ,act 7#db
 ,u4,s4,c4 #acbj;d-#b74  7c7 ,prohibited
 contractual provisions ,any provision  
in an agreement that unduly delays or   
limits a group health plan that is a    
self-funded1 non-,federal governmental  
plan's access to information described  
in this section or that restricts the   
format or timing of the provision of    
such information in a manner that is    
inconsistent with the requirements of   
this section shall be prohibited and1 if
 a self-funded1 non-,federal            
governmental plan enters into such      
agreement1 shall be deemed void as      
against public policy4  7d7 ,regulations
 ,the ,secretary shall implement this   

section through notice and comment      
rulemaking in accordance with section   
#eec of title #e1 ,united ,states ,code4
  4  7#b7 ,penalty ,section #bgbc7;b7 of
 the ,public ,health ,service ,act 7#db 
,u4,s4,c4 #cjj;gg-#bb7;b77 is amended by
 adding at the end the following3  7#d7 
,enforcement authority relating to      
health plan service providers           
,notwithstanding any provisions to the  
contrary1 the ,secretary may assess a   
penalty against a health plan service   
provider1 as defined in section         
#bgii;,a-#aa7;a7 7#db ,u4,s4,c4         
#cjj;gg-#aba7;a771 of #ajj1jjj per day  
for each violation of such section1     
pursuant to substantially similar       
processes and procedures as those set   
forth in section #bgbc7;b77#b77;,d7     
through 7,g7 7#db ,u4,s4,c4             
#cjj;gg-#aba7;b77#b77;,d7 through 7,g774
  4  #i4 ,state preemption only in event
 of conflict ,the provisions of sections
 #b through #e 7including the amendments
 made by such sections7 shall not       

supersede any provision of ,state law   
which establishes1 implements1 or       
continues in effect any requirement or  
prohibition related to health care price
 transparency1 including hospital1      
clinical diagnostic laboratory tests1   
imaging services1 and ambulatory        
surgical center1 except to the extent   
that such requirement or prohibition    
prevents the application of a           
requirement or prohibition of such      
sections 7or amendment74 ,nothing in    
this section shall be construed to      
affect group health plans established   
under the ,employee ,retirement ,income 
,security ,act of #aigd1 or alter the   
application of section #ead of such ,act
 7#bi ,u4,s4,c4 #aadd74  #aj4           
,requirement for explanation of benefits
  7a7 ,,phsa ,amendments  7#a7          
,emergency services ,section            
#bgii;,a-#a7;f77#a77;,c7 of the ,public 
,health ,service ,act 7#db ,u4,s4,c4    
#cjj;gg-#aaa7;f77#a77;,c77 is amended to
 read as follows3  7,c7 ,a good faith   

estimate of the amount the plan or      
coverage is responsible for paying for  
items and services included in the      
estimate described in subparagraph 7,b71
 including a plain language description 
of each item or service and all         
applicable billing codes for each item  
or service1 including modifiers1 using  
standard and commonly recognized billing
 code sets that are clearly identified4 
4  7#b7 ,explanation of benefits        
,section #bgii;,a-#a of the ,public     
,health ,service ,act 7#db ,u4,s4,c4    
#cjj;gg-#aaa7 is amended by adding at   
the end the following3  7g7 ,explanation
 of benefits  7#a7 ,in general ,for plan
 years beginning on or after ,january   
#a1 #bjbf1 each group health plan1 or a 
health insurance issuer offering group  
or individual health insurance coverage 
shall1 within #de days of receiving any 
request for payment for an item or      
service under the plan1 provide to the  
participant1 beneficiary1 or enrollee   
7through mail or electronic means1 as   

requested by the participant1           
beneficiary1 or enrollee7 a notification
 7in clear and understandable language  
and utilizing substantially the same    
format as the advanced explanation of   
benefits required by subsection 7f7 to  
enable comparison7 including the        
following3 7,a7 ,whether or not the     
provider or facility is a participating 
provider or a participating facility    
with respect to the plan or coverage    
with respect to the furnishing of such  
item or service4  7,b7 ,an itemized     
explanation of benefits that includes   
the following3 7i7 ,a plain language    
description of each item or service4    
7ii7 ,all applicable billing codes for  
each item or service1 including         
modifiers1 using standard and commonly  
recognized billing code sets that are   
clearly identified4  7iii7 ,the amount  
the plan or coverage is responsible for 
paying for each item or service4  7iv7  
,the amount of any cost-sharing for     
which the participant1 beneficiary1 or  

enrollee is responsible for each item or
 service 7as of the date of such        
notification74  7v7 ,the amount that the
 participant1 beneficiary1 or enrollee  
has incurred toward meeting the limit of
 the financial responsibility 7including
 with respect to deductibles and        
out-of-pocket maximums7 under the plan  
or coverage 7as of the date of such     
notification74  7vi7 ,the site of each  
item or service4  7#b7 ,format ,if      
applicable1 the notification described  
in paragraph 7#a7 may be provided in    
conjunction with1 or as part of1 a      
notice of a claim determination or other
 communication required by section      
#bgai7;a7 7#db ,u4,s4,c4                
#cjj;gg-#ai7;a771 or regulations        
thereunder4  7h7 ,regulations ,the      
,secretary shall implement this section 
through notice and comment rulemaking in
 accordance with section #eec of title  
#e1 ,united ,states ,code4  4  7b7 ,,irc
 amendments  7#a7 ,emergency services   
,section #ihaf7;f77#a77;,c7 of the      

,internal ,revenue ,code of #aihf is    
amended to read as follows3  7,c7 ,a    
good faith estimate of the amount the   
plan is responsible for paying for items
 and services included in the estimate  
described in subparagraph 7,b71         
including a plain language description  
of each item or service and all         
applicable billing codes for each item  
or service1 including modifiers1 using  
standard and commonly recognized billing
 code sets that are clearly identified4 
4  7#b7 ,explanation of benefits        
,section #ihaf of the ,internal ,revenue
 ,code of #aihf is amended by adding at 
the end the following3  7g7 ,explanation
 of benefits  7#a7 ,in general ,for plan
 years beginning on or after ,january   
#a1 #bjbf1 each group health plan shall1
 within #de days of receiving any       
request for payment for an item or      
service under the plan1 provide to the  
participant or beneficiary 7through mail
 or electronic means1 as requested by   
the participant or beneficiary7 a       

notification 7in clear and              
understandable language and utilizing   
substantially the same format as the    
advanced explanation of benefits        
required by subsection 7f7 to enable    
comparison7 including the following3    
7,a7 ,whether or not the provider or    
facility is a participating provider or 
a participating facility with respect to
 the plan with respect to the furnishing
 of such item or service4  7,b7 ,an     
itemized explanation of benefits that   
includes the following3 7i7 ,a plain    
language description of each item or    
service4  7ii7 ,all applicable billing  
codes for each item or service1         
including modifiers1 using standard and 
commonly recognized billing code sets   
that are clearly identified4  7iii7 ,the
 amount the plan is responsible for     
paying for each item or service4  7iv7  
,the amount of any cost-sharing for     
which the participant or beneficiary is 
responsible for each item or service 7as
 of the date of such notification74  7v7

 ,the amount that the participant or    
beneficiary has incurred toward meeting 
the limit of the financial              
responsibility 7including with respect  
to deductibles and out-of-pocket        
maximums7 under the plan 7as of the date
 of such notification74  7vi7 ,the site 
of each item or service4  7#b7 ,format  
,if applicable1 the notification        
described in paragraph 7#a7 may be      
provided in conjunction with1 or as part
 of1 a notice of a claim determination  
or other communication required by      
section #ejc of the ,employee           
,retirement ,income ,security ,act of   
#aigd or regulations thereunder4  7h7   
,regulations ,the ,secretary shall      
implement this section through notice   
and comment rulemaking in accordance    
with section #eec of title #e1 ,united  
,states ,code4  4  7c7 ,,erisa          
amendments  7#a7 ,emergency services    
,section #gaf7;f77#a77;,c7 of the       
,employee ,retirement ,income ,security 
,act of #aigd 7#bi ,u4,s4,c4            

#aahe;e7f77#a77;,c77 is amended to read 
as follows3  7,c7 ,a good faith estimate
 of the amount the health plan is       
responsible for paying for items and    
services included in the estimate       
described in subparagraph 7,b71         
including a plain language description  
of each item or service and all         
applicable billing codes for each item  
or service1 including modifiers1 using  
standard and commonly recognized billing
 code sets that are clearly identified4 
4  7#b7 ,explanation of benefits        
,section #gaf of the ,employee          
,retirement ,income ,security ,act of   
#aigd 7#bi ,u4,s4,c4 #aahe;e7 is amended
 by adding at the end the following3    
7g7 ,explanation of benefits  7#a7 ,in  
general ,for plan years beginning on or 
after ,january #a1 #bjbf1 each group    
health plan or health insurance issuer  
offering group health insurance coverage
 shall1 within #de days of receiving any
 request for payment for an item or     
service under the plan1 provide to the  

participant or beneficiary 7through mail
 or electronic means1 as requested by   
the participant or beneficiary7 a       
notification 7in clear and              
understandable language and utilizing   
substantially the same format as the    
advanced explanation of benefits        
required by subsection 7f7 to enable    
comparison7 including the following3    
7,a7 ,whether or not the provider or    
facility is a participating provider or 
a participating facility with respect to
 the plan or coverage with respect to   
the furnishing of such item or service4 
7,b7 ,an itemized explanation of        
benefits that includes the following3   
7i7 ,a plain language description of    
each item or service4  7ii7 ,all        
applicable billing codes for each item  
or service1 including modifiers1 using  
standard and commonly recognized billing
 code sets that are clearly identified4 
7iii7 ,the amount the plan or coverage  
is responsible for paying for each item 
or service4  7iv7 ,the amount of any    

cost-sharing for which the participant  
or beneficiary is responsible for each  
item or service 7as of the date of such 
notification74  7v7 ,the amount that the
 participant or beneficiary has incurred
 toward meeting the limit of the        
financial responsibility 7including with
 respect to deductibles and             
out-of-pocket maximums7 under the plan  
or coverage 7as of the date of such     
notification74  7vi7 ,the site of each  
item or service4  7#b7 ,format ,if      
applicable1 the notification described  
in paragraph 7#a7 may be provided in    
conjunction with1 or as part of1 a      
notice of a claim determination or other
 communication required by section #ejc 
or regulations thereunder4  7h7         
,regulations ,the ,secretary shall      
implement this section through notice   
and comment rulemaking in accordance    
with section #eec of title #e1 ,united  
,states ,code4  4  #aa4 ,provision of   
itemized bills ,part ,e of title ,,xxvii
 of the ,public ,health ,service ,act   

7#db ,u4,s4,c4 #cjj;gg-#aca et seq47 is 
amended by adding at the end the        
following3  #bgii;,b-#aj4 ,provider     
requirements for itemized bills  7a7    
,requirements  7#a7 ,itemized bill and  
other information required  7,a7 ,in    
general ,a health care provider or      
health care facility that requests      
payment from an individual after        
providing a health care item or service 
to the patient shall include with such  
request a written1 itemized bill of the 
cost of each reasonably expected item or
 service the health care provider or    
health care facility provided to the    
individual1 including telehealth visits 
or visits by other electronic means4    
,the health care provider or health care
 facility shall provide the itemized    
bill not later than #cj days after the  
health care provider or health care     
facility received a final payment on the
 provided service or supply from a third
 party4  7,b7 ,required information ,for
 each item or service provided by the   

health care provider or facility or for 
which the health care provider or       
facility is billing the individual1 the 
itemized bill must include-- 7i7 a plain
 language description of each distinct  
health care item or service2  7ii7 all  
applicable billing codes for each       
distinct health care item or service1   
including modifiers1 using standard and 
commonly recognized billing code sets   
that are clearly identified2  7iii7 the 
price and billed amount1 if different1  
of each distinct health care item or    
service or if the provider or facility  
is offering binding1 all-in prices for  
bundled items and services1 the total   
binding price for bundled items and     
services and billed amount2  7iv7 any   
payments made to the health care        
provider or health care facility by or  
on behalf of the individual 7including  
payments by any health plan or          
insurance7 for any health care item or  
service covered in the itemized bill2   
7v7 information about the availability  

of language-assistance services for     
individuals with limited ,english       
proficiency 7,,lep72  7vi7 the          
identification of an office or          
individual at the health care provider  
or health care facility1 including phone
 number and email address1 that shall be
 able to discuss the specific details of
 the itemized statement and be          
authorized to make appropriate changes  
thereto2 and  7vii7 information about   
the health care provider's or health    
care facility's charity care policies   
and instructions on how to apply for    
charity care4  7#b7 ,collections actions
  7,a7 ,in general ,a health care       
provider or health care facility shall  
not take any collections actions against
 an individual-- 7i7 for any provided   
health care item or service unless the  
health care provider or health care     
facility has complied with paragraph    
7#a72 or  7ii7 with respect to any items
 or services for which the amount       
appearing on an itemized bill described 

above in paragraph 7#a7 exceeds the     
amount disclosed pursuant to ,federal   
health care price transparency          
regulations1 including part #ahj of     
title #de1 ,code of ,federal            
,regulations1 or provided in a good     
faith estimate that complies with       
section #bgii;,b-#f of this ,act and    
section #adi4faj of title #de1 ,code of 
,federal ,regulations1 or another good  
faith estimate provided by a health care
 entity covered under this section but  
not otherwise covered under such section
 #bgii;,b-#f unless the provider or     
facility documents that the additional  
items or services were medically        
necessary due to unforeseen             
complications or a patient-initiated    
change1 and could not reasonably have   
been anticipated4  7,b7 ,burden of proof
 ,the burden of proof under subparagraph
 7,a77ii7 shall rest with the provider1 
and absent the documentation described  
in such subparagraph1 the good faith    
estimate shall be binding4  7b7 ,failure

 ,to comply  7#a7 ,penalties ,the       
,secretary shall impose penalties on any
 health care provider or health care    
facility that fails to comply with the  
requirements of this section in an      
amount not to exceed #aj1jjj for each   
instance of failure to comply4  7#b7    
,presumption in favor of individual ,if 
a health care provider or health care   
facility fails to comply with the       
requirements of this section1 the       
presumption shall be that charges were  
substantially in excess of the good     
faith estimate 7as set forth in section 
#bgii;,b-#f7 for the purpose of any     
patient-provider dispute1 including in  
accordance with section #bgii;,b-#g and 
regulations promulgated thereunder4  7c7
 ,regulations ,the ,secretary shall     
implement this section through notice   
and comment rulemaking in accordance    
with section #eec of title #e1 ,united  
,states ,code4  4