,,ii ,calendar ,no4 #ebb #aaith ,,congress #b;d ,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 ,ms4 ,ernst1 ,ms4 ,baldwin1 ,mr4 ,moreno1 ,mr4 ,scott of ,florida1 ,mr4 ,kim1 ,mr4 ,husted1 ,ms4 ,blunt ,rochester1 ,mr4 ,tuberville1 ,ms4 ,lummis1 ,mr4 ,coons1 ,mr4 ,mullin1 ,mr4 ,booker1 ,mr4 ,welch1 ,mr4 ,peters1 ,ms4 ,warren1 ,mr4 ,armstrong1 ,mr4 ,kelly1 ,mr4 ,schmitt1 ,mr4 ,fetterman1 and ,mr4 ,gallego7 introduced the following bill2 which was read twice and referred to the ,committee on ,health1 ,education1 ,labor1 and ,pensions ,july #bg1 #bjbf,reported by ,mr4 ,cassidy1 with an amendment,strike out all after the enacting clause and insert the part printed in italic ,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 #a4 ,short title ,this ,act may be cited as the ,patients ,deserve ,price ,tags ,act4 #b4 ,strengthening hospital price transparency ,title ,,xxvii of the ,public ,health ,service ,act is amended by inserting after section #bgah 7#db ,u4,s4,c4 #cjj;gg-#ah7 the following3 #bgah;,a4 ,provider price transparency 7a7 ,definitions ,in this section3 7#a7 ,applicable imaging service provider ,the term applicable imaging provider means a provider of services or supplier who furnishes any imaging services to patients1 including an independent diagnostic testing facility1 an outpatient diagnostic facility1 and any other imaging center designated by the ,secretary1 except that such term does not include an imaging service provider with respect to which standard charges for specified imaging service provider services furnished by such service provider are made available by a hospital pursuant to subsection 7b7 or specified ambulatory surgical center pursuant to subsection 7e74 7#b7 ,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 for specified clinical diagnostic laboratory tests furnished by such laboratory are made available by a hospital pursuant to subsection 7b7 or specified ambulatory surgical center pursuant to subsection 7e74 7#c7 ,discounted cash price 7,a7 ,in general ,the term discounted cash price means the minimum charge expressed as a dollar amount1 subject to subparagraph 7,b71 that the applicable service provider subject to this section accepts from an individual who pays cash1 or cash equivalent1 for a furnished item or service1 without regard to health insurance coverage1 as payment in full4 7,b7 ,exclusions ,for purposes of subparagraph 7,a71 the minimum charge described in such subparagraph1 with respect to a furnished item or service1 as applicable1 shall be calculated without taking into account any financial assistance1 including assistance attributable to charity care 7in the case of a hospital1 as such term is used for purposes of hospital cost reporting under title ,,xviii of the ,social ,security ,act71 or third-party assistance for such item or service4 7#d7 ,extraordinary collection actions ,the term extraordinary collection action has the meaning given such term for purposes of section #eja7r7 of the ,internal ,revenue ,code of #aihf4 7#e7 ,gross charge ,the term gross charge means the charge for an individual item or service that is reflected on a hospital's chargemaster or similar list of prices facilitated by any other provider1 as defined by the ,secretary1 absent any discounts4 7#f7 ,hospital ,the term hospital means an institution in any ,state in which ,state or applicable local law provides for the licensing of hospitals1 that is licensed as a hospital pursuant to such law or is approved1 by the agency of such ,state or locality responsible for licensing hospitals1 as meeting the standards established for such licensing4 ,for purposes of this paragraph1 the term ,state includes each of the several ,states1 the ,district of ,columbia1 ,puerto ,rico1 the ,virgin ,islands1 ,guam1 ,american ,samoa1 and the ,northern ,mariana ,islands4 7#g7 ,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#h7 ,shoppable service ,the term shoppable service means a service that can be scheduled by a healthcare consumer in advance4 ,such services are routinely provided in non-urgent situations that do not require immediate action or attention to the patient1 thus allowing patients to price shop and schedule a service at a time that is convenient for them4 7#i7 ,specified ambulatory surgical center ,the term specified ambulatory surgical center means any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed #bd hours following an admission1 except that such term does not include a surgical center with respect to which standard charges for specified ambulatory surgical center services furnished by such surgical center are made available by a hospital pursuant to subsection 7b74 7#aj7 ,specified clinical diagnostic laboratory test ,the term specified clinical diagnostic laboratory test means any clinical diagnostic laboratory test or service that is provided by the applicable laboratory1 excluding advanced diagnostic laboratory tests 7as defined in section #ahcd;,a7d77#e7 of the ,social ,security ,act74 7#aa7 ,specified imaging service ,the term specified imaging service has the meaning given to the term radiology and certain other imaging services for purposes of section #daa4cea of title #db1 ,code of ,federal ,regulations 7or successor regulations74 7#ab7 ,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 7b7 ,hospital price transparency 7#a7 ,in general ,beginning ,january #a of the year that begins on or after the date that is #a year after the date of enactment of the ,patients ,deserve ,price ,tags ,act1 each hospital shall1 in accordance with a method and format established by the ,secretary under paragraph 7#c71 on a quarterly basis 7if there have been any changes to the standard charges described in subparagraph 7#b7 compile and make publicly available on an internet website 7without subscription and free of charge7-- 7,a7 all of the hospital's standard charges for each item and service furnished by such hospital in a machine-readable format 7or a successor technology specified by the ,secretary72 7,b7 all of the hospital's standard charges in a consumer-friendly format 7as specified by the ,secretary71 that includes-- 7i7 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 the ,january #a described in this subparagraph1 after which the hospital shall include all shoppable services that the hospital furnishes2 and 7ii7 with respect to each ,centers for ,medicare ,medicaid ,services-specified shoppable service that is not furnished by the hospital1 an indication that such service is not so furnished2 and 7,c7 the name and business address for each person or entity that1 with respect to the hospital-- 7i7 has an ownership or investment interest2 7ii7 has a controlling interest2 7iii7 is a management services organization2 or 7iv7 is a significant equity investor4 7#b7 ,standard charges defined ,for purposes of paragraph 7#a71 the term standard charges means the following3 7,a7 ,a plain language description of each item and service1 accompanied by any applicable billing codes1 including modifiers1 using commonly recognized billing code sets1 including-- 7i7 the ,diagnosis ,related ,group2 7ii7 the ,healthcare ,common ,procedure ,coding ,system code2 7iii7 the ,national ,drug ,code2 and 7iv7 other applicable identifiers as determined by the ,secretary 7or successor code sets74 7,b7 ,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 7,c7 ,the discounted cash price4 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 hospital shall also disclose such algorithm1 percentage1 formula1 or criteria as set forth in its contract and any other information necessary to determine the negotiated charge as a dollar amount4 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 ,the amount of any facility fee1 as defined by the ,secretary1 or add-on charges that will be part of the final payment amount1 in addition to any information that might help the patient understand when a facility fee or add-on charge may apply and how to avoid such charges4 7,g7 ,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 for an item or service1 except information that is duplicative of any other reporting requirement under this subsection4 ,in the case of standard charges 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 ,the ,secretary shall establish a standard1 uniform method and format for hospitals to use in compiling and making public information described in paragraph 7#a74 ,such method and format shall-- 7,a7 include a machine-readable format 7or successor technology specified by the ,secretary7 containing the information described in paragraph 7#b7 for all items and services furnished by each hospital2 7,b7 meet such standards as determined appropriate by the ,secretary in order to ensure the accessibility and usability of such charges2 and 7,c7 be updated as determined appropriate by the ,secretary1 in consultation with stakeholders4 7#d7 ,no deemed compliance ,hospitals may offer a price estimator tool1 but the availability of such a price estimator tool shall not be considered to deem compliance with or otherwise vitiate the requirements of paragraph 7#a77;,b7 or any other requirements of this subsection4 7#e7 ,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#f7 ,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 disclosures1 and any other attestations as required by the ,secretary1 made in accordance with the hospital price transparency requirements based on criteria established by the ,secretary4 7#g7 ,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 notify such hospital of such determination1 which shall include a request for a corrective action plan if applicable 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 #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 on the day the hospital was first out of compliance1 as determined by the ,secretary7 during which such failure was ongoing4 ,such amount shall not exceed-- 7,i7 in the case of a specified hospital with #cj or fewer beds1 #cjj per day 7or1 in the case of such a hospital that has been noncompliant with such requirements for a #a-year period or longer1 beginning with the first day following such #a-year period1 #djj per day72 7,,ii7 in the case of a specified hospital with more than #cj beds but fewer than #aja beds1 #ab4ej per bed per day 7or1 in the case of such a hospital that has been noncompliant with such requirements for a #a-year period or longer1 beginning with the first day following such #a-year period1 #ae per bed per day72 7,,iii7 in the case of a specified hospital with more than #ajj beds but fewer than #bja beds1 #ag4ej per bed per day 7or1 in the case of such a hospital that has been noncompliant with such requirements for a #a-year period or longer1 beginning with the first day following such #a-year period1 #bj per bed per day72 7,,iv7 in the case of a specified hospital with more than #bjj beds but fewer than #eja beds1 #bj per bed per day 7or1 in the case of such a hospital that has been noncompliant with such requirements for a #a-year period or longer1 beginning with the first day following such #a-year period1 #be per bed per day72 and 7,v7 in the case of a specified hospital with more than #ejj beds1 #be per bed per day 7or1 in the case of such a hospital that has been noncompliant with such requirements for a #a-year period or longer1 beginning with the first day following such #a-year period1 #ce per bed per day74 7ii7 ,increase authority ,in applying this subparagraph with respect to hospitals that fail to comply in #bjbh 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 noncompliant with the provisions of this subsection two or more times during a #a-year period 7as determined by the ,secretary71 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 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 7,c7 ,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 failing to comply with the requirements of this subsection except where the ,secretary determines that imposing the maximum civil monetary penalty1 including penalties for persistent noncompliance1 will disrupt hospital operations in a manner that impacts patient care4 ,the ,secretary may request documentation in such form and manner as the ,secretary may require in order to evaluate impact on hospital operations4 7,d7 ,prohibition on extraordinary collection ,in addition to civil monetary penalties applicable under subparagraph 7,b7 and any other enforcement actions or penalties that may apply under any other provision of law1 for 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 #ij days after such request1 that hospital or any other person or entity collecting on behalf of the hospital shall-- 7i7 not take any extraordinary collection actions against any patient or patient guarantor for debt incurred by any patient on the date or dates of service when the hospital was not in compliance with the requirements of this subsection2 7ii7 cease any extraordinary collection actions that have begun against any patient or patient guarantor for debt incurred by any patient on the date or dates of service when the hospital was not in compliance with the requirements of this subsection2 and 7iii7 not take any extraordinary collection actions against any patient or patient guarantor for debt incurred by any patient on the date or dates of service when the hospital was not in compliance with the requirements of this subsection after the hospital comes back into compliance with the requirements of this subsection4 7#h7 ,rulemaking 7,a7 ,in general ,the ,secretary shall implement this subsection through notice and comment rulemaking in accordance with section #eec of title #e1 ,united ,states ,code4 7,b7 ,ownership information ,in promulgating regulations under this paragraph1 the ,secretary shall define the individuals and organizations that must be disclosed under paragraph 7#a77;,c7 in a manner that harmonizes disclosure requirements with requirements established under section #aabd of the ,social ,security ,act and prioritizes the disclosure of individuals and organizations who's ownership or management relationship with a hospital impacts operational1 financial1 or clinical decision making for such hospital4 4 #c4 ,clinical diagnostic laboratory price transparency ,section #bgah;,a of the ,public ,health ,service ,act1 as added by section #b1 is amended by adding at the end the following3 7c7 ,clinical diagnostic laboratory price transparency 7#a7 ,in general ,beginning ,january #a of the year that begins on or after the date that is #a year after the date of enactment of the ,patients ,deserve ,price ,tags ,act1 an applicable laboratory shall1 on a quarterly basis 7if there have been any changes to the standard charges described in paragraph 7#b77 compile and make publicly available on an internet website 7without subscription and free of charge7-- 7,a7 the standard charges described in paragraph 7#b7 with respect to each specified clinical diagnostic laboratory test that such laboratory so furnishes2 and 7,b7 the name and business address for each person or entity that1 with respect to the laboratory-- 7i7 has an ownership or investment interest2 7ii7 has a controlling interest2 7iii7 is a management services organization2 or 7iv7 is a significant equity investor4 7#b7 ,standard charges defined ,for purposes of paragraph 7#a71 the term standard charges means1 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 codes 7including modifiers that materially change the price for insurers or providers1 and that materially change out-of-pocket costs for consumers7 using commonly recognized billing code sets1 including-- 7i7 the ,healthcare ,common ,procedure ,coding ,system code2 7ii7 the ,national ,drug ,code2 or 7iii7 other applicable identifier as determined by the ,secretary 7or successor code sets74 7,b7 ,the gross charge expressed as a dollar amount1 for each such test4 7,c7 ,the discounted cash price4 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 test4 ,if the charges are based on an algorithm1 percentage of another amount1 or other formula or criteria1 the applicable laboratory also shall disclose such algorithm1 percentage1 formula1 or criteria as set forth in its contract and any other information necessary to determine the negotiated charge as a dollar amount4 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 for an item or service1 except information that is duplicative of any other reporting requirement under this section4 ,in the case of standard charges 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 ,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 format 7or a successor technology specified by the ,secretary7 containing the information described in paragraph 7#b7 for all specified clinical diagnostic laboratory tests furnished by each laboratory and the ownership information described in paragraph 7#a77;,b72 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 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 applicable laboratory's compliance with this subsection is reviewed not less frequently than once every year4 7#e7 ,inclusion of ancillary services ,any charge for a specified clinical diagnostic laboratory test furnished by an applicable laboratory made publicly available in accordance with paragraph 7#a7 shall include the charge for any ancillary item or service 7such as 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#f7 ,attestation ,a senior official from each clinical diagnostic laboratory 7the ,chief ,executive ,officer1 ,chief ,financial ,officer1 or an official of equivalent seniority7 shall attest to the accuracy and completeness of the disclosures1 and any other attestations as required by the ,secretary1 made in accordance with the clinical laboratory price transparency requirements based on criteria established by the ,secretary4 7#g7 ,enforcement 7,a7 ,in general ,in the case of an applicable laboratory that fails to comply with the requirements of this subsection-- 7i7 the ,secretary shall notify such laboratory 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 such laboratory 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 ,an applicable laboratory 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 applicable laboratory 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 laboratory 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 an applicable laboratory that fails to comply with the requirements of this subsection in #bjbh or a subsequent year1 the ,secretary may through notice and comment rulemaking increase the limitation on the per day amount of any penalty applicable to an applicable laboratory 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 failing to comply with the requirements of this subsection except where the ,secretary determines that imposing the maximum civil monetary penalty will disrupt applicable laboratory operations in a manner that impacts patient care4 ,the ,secretary may request documentation in such form and manner as the ,secretary may require in order to evaluate impact on applicable laboratory operations4 7#h7 ,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#i7 ,rulemaking 7,a7 ,in general ,the ,secretary shall implement this subsection through notice and comment rulemaking in accordance with section #eec of title #e1 ,united ,states ,code4 7,b7 ,ownership information ,in promulgating regulations under this paragraph1 the ,secretary shall define the individuals and organizations that must be disclosed under paragraph 7#a77;,c7 in a manner that harmonizes disclosure requirements with requirements established under section #aabd of the ,social ,security ,act and prioritizes the disclosure of individuals and organizations who's ownership or management relationship with a hospital impacts operational1 financial1 or clinical decision making for such hospital4 4 #d4 ,imaging services price transparency ,section #bgah;,a of the ,public ,health ,service ,act1 as amended by section #c1 is further amended by adding at the end the following3 7d7 ,imaging services price transparency 7#a7 ,in general ,beginning ,january #a of the year that begins on or after the date that is #a year after the date of enactment of the ,patients ,deserve ,price ,tags ,act1 each applicable imaging service provider shall1 on a quarterly basis 7if there have been any changes to the standard charges described in paragraph 7#b77 compile and make publicly available on an internet website 7without subscription and free of charge7-- 7,a7 the standard charges described in paragraph 7#b7 with respect to each such specified imaging service provided by such provider2 and 7,b7 the name and business address for each person or entity that1 with respect to the imaging services provider-- 7i7 has an ownership or investment interest2 7ii7 has a controlling interest2 7iii7 is a management services organization2 or 7iv7 is a significant equity investor4 7#b7 ,standard charges defined ,for purposes of paragraph 7#a71 the term standard charges1 with respect to an applicable imaging service provider and a specified imaging service1 means the following3 7,a7 ,a plain language description of each item or service1 accompanied by any applicable billing codes 7including modifiers that materially change the price for insurers or providers1 and that materially change out-of-pocket costs for consumers7 using commonly recognized billing code sets1 including-- 7i7 the ,healthcare ,common ,procedure ,coding ,system code2 7ii7 the ,national ,drug ,code2 or 7iii7 other applicable identifier as determined by the ,secretary 7or successor code sets74 7,b7 ,the gross charge expressed as a dollar amount1 for each such item or service4 7,c7 ,the discounted cash price4 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 service4 ,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 information necessary to determine the negotiated charge as a dollar amount4 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 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 ,the ,secretary shall establish a standard1 uniform method and format for applicable imaging service providers to use in making public information described in paragraph 7#a74 ,any such method and format shall-- 7,a7 include a machine-readable format 7as specified by the ,secretary7 containing the information described in paragraph 7#b7 for all specified imaging services furnished by each applicable imaging service provider and ownership information described in paragraph 7#a77;,b72 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 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 ,attestation ,a senior official from each specified imaging service provider 7the ,chief ,executive ,officer1 ,chief ,financial ,officer1 or an official of equivalent seniority7 shall attest to the accuracy and completeness of the disclosures1 and any other attestations as required by the ,secretary1 made in accordance with the imaging service provider price transparency requirements based on criteria established by the ,secretary4 7#f7 ,enforcement 7,a7 ,in general ,in the case of a specified imaging service provider that fails to comply with the requirements of this subsection-- 7i7 the ,secretary shall notify such imaging service provider 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 such imaging service provider 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 imaging service provider 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 a specified imaging service provider 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 imaging service provider 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 a specified imaging service provider that fails to comply with the requirements of this subsection in #bjbh 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 imaging service provider 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 failing to comply with the requirements of this subsection except where the ,secretary determines that imposing the maximum civil monetary penalty will disrupt specified imaging service provider operations in a manner that impacts patient care4 ,the ,secretary may request documentation in such form and manner as the ,secretary may require in order to evaluate impact on specified imaging service provider operations4 7#g7 ,provision of technical assistance ,the ,secretary shall1 to the extent practicable1 provide technical assistance relating to compliance with the provisions of this subsection to providers of services and suppliers requesting such assistance4 7#h7 ,rulemaking 7,a7 ,in general ,the ,secretary shall implement this subsection through notice and comment rulemaking in accordance with section #eec of title #e1 ,united ,states ,code4 7,b7 ,ownership information ,in promulgating regulations under this paragraph1 the ,secretary shall define the individuals and organizations that must be disclosed under paragraph 7#a77;,c7 in a manner that harmonizes disclosure requirements with requirements established under section #aabd of the ,social ,security ,act and prioritizes the disclosure of individuals and organizations who's ownership or management relationship with a hospital impacts operational1 financial1 or clinical decision making for such hospital4 4 #e4 ,ambulatory surgical center price transparency ,section #bgah;,a of the ,public ,health ,service ,act1 as amended by section #d1 is further amended by adding at the end the following3 7e7 ,ambulatory surgical center price transparency 7#a7 ,in general ,beginning ,january #a of the year that begins on or after the date that is #a year after the date of enactment of the ,patients ,deserve ,price ,tags ,act1 each specified ambulatory surgical center shall1 on a quarterly basis 7if there have been any changes to the standard charges described in paragraph 7#b771 compile and make publicly available on an internet website 7without subscription and free of charge7-- 7,a7 the standard charges described in paragraph 7#b7 with respect to each specified service furnished by such surgical center2 and 7,b7 the name and business address for each person or entity that1 with respect to the ambulatory surgical center-- 7i7 has an ownership or investment interest2 7ii7 has a controlling interest2 7iii7 is a management services organization2 or 7iv7 is a significant equity investor4 7#b7 ,standard charges defined ,for purposes of paragraph 7#a71 the term standard charges with respect to standard charges and prices made public by a specified ambulatory surgical center means the following3 7,a7 ,a plain language description of each item or service1 accompanied by any applicable billing codes 7including modifiers that materially change the price for insurers or providers1 and that materially change out-of-pocket costs for consumers7 using commonly recognized billing code sets1 including-- 7i7 the ,healthcare ,common ,procedure ,coding ,system code2 7ii7 the ,national ,drug ,code2 or 7iii7 other applicable identifier as determined by the ,secretary 7or successor code sets74 7,b7 ,the gross charge1 expressed as a dollar amount1 for each such item or service4 7,c7 ,the discounted cash price4 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 service4 ,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 information necessary to determine the negotiated charge as a dollar amount4 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 service4 ,in the case of standard charges 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 ,the ,secretary shall establish a standard1 uniform method and format for specified ambulatory surgical centers to use in compiling and making public information pursuant to paragraph 7#a74 ,such method and format shall-- 7,a7 include a machine-readable format 7or a successor technology specified by the ,secretary7 containing the information described in paragraph 7#b7 for all specified services furnished by each ambulatory surgical center and for the ownership information described in paragraph 7#a77;,b72 7,b7 meet such standards as determined appropriate by the ,secretary in order to ensure the accessibility and usability of such charges2 and 7,c7 be updated as determined appropriate by the ,secretary1 in consultation with stakeholders4 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 ,attestation ,a senior official from each specified ambulatory surgical center 7the ,chief ,executive ,officer1 ,chief ,financial ,officer1 or an official of equivalent seniority7 shall attest to the accuracy and completeness of the disclosures1 and any other attestations as required by the ,secretary1 made in accordance with the ambulatory center price transparency requirements based on criteria established by the ,secretary4 7#f7 ,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 such 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 a specified 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 ambulatory surgical center 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 a specified ambulatory surgical center that fails to comply with the requirements of this subsection in #bjbh 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 failing to comply with the requirements of this subsection except where the ,secretary determines that imposing the maximum civil monetary penalty will disrupt specified ambulatory surgical center operations in a manner that impacts patient care4 ,the ,secretary may request documentation in such form and manner as the ,secretary may require in order to evaluate impact on specified ambulatory surgical center operations4 7#g7 ,provision of technical assistance ,the ,secretary shall1 to the extent practicable1 provide technical assistance relating to compliance with the provisions of this subsection to specified ambulatory surgical centers requesting such assistance4 7#h7 ,rulemaking 7,a7 ,in general ,the ,secretary shall implement this subsection through notice and comment rulemaking in accordance with section #eec of title #e1 ,united ,states ,code4 7,b7 ,ownership information ,in promulgating regulations under this paragraph1 the ,secretary shall define the individuals and organizations that must be disclosed under paragraph 7#a77;,c7 in a manner that harmonizes disclosure requirements with requirements established under section #aabd of the ,social ,security ,act and prioritizes the disclosure of individuals and organizations who's ownership or management relationship with a hospital impacts operational1 financial1 or clinical decision making for such hospital4 7f7 ,continued applicability of ,state law ,the provisions of this section 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 section4 4 #f4 ,strengthening health coverage transparency requirements 7a7 ,transparency in coverage ,section #bgae;,a of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ae;a7 is amended-- 7#a7 by striking ,a ,group health and inserting the following3 7a7 ,in general ,a group health 2 and 7#b7 by ending at the end the following3 7b7 ,additional transparency requirements 7#a7 ,specified information required 7,a7 ,in general ,a group health plan or health insurance issuer offering coverage in the individual or group market shall provide to each participant1 beneficiary1 or enrollee1 at the time of enrollment in the plan or coverage1 the information described in subparagraph 7,b74 7,b7 ,information required ,for purposes of subparagraph 7,a71 the information specified in this subparagraph is1 with respect to benefits available under the plan or coverage for an item or service furnished by a health care provider1 the following 7or other information as determined appropriate by the ,secretary73 7i7 ,if such provider is an in-network provider with respect to such item or service1 the in-network rate 7as defined in paragraph 7#e77 for such item or service4 7ii7 ,if such provider is not described in clause 7i71 the out-of-network allowed amount 7as such term is defined for purposes of section #adg4baj7;a77#b77xvii7 of title #de1 ,code of ,federal ,regulation7 for such item or service that the plan or coverage will pay without regard to the amount in clause 7iii74 7iii7 ,the amount of cost-sharing liability 7including deductibles1 copayments1 and coinsurance7 that the individual will incur for such item or service based on the information available to the plan or coverage at the time the request is made 7which1 in the case such item or service is to be furnished by a provider described in clause 7ii71 shall be calculated using the maximum amount described in such clause74 7iv7 ,the accumulated amounts with respect to any deductible or out-of-pocket maximum under the plan or coverage reflected in the plan's or coverage's records at the time the request is made 7broken down1 in the case separate deductibles or maximums apply to separate individuals enrolled in the plan or coverage1 by such separate deductibles or maximums1 in addition to any cumulative deductible or maximum74 7v7 ,in the case such plan or coverage 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 service reflected in the plan's or coverage's records at the time the request is made4 7vi7 ,information about any utilization management requirements1 such as prior authorization1 concurrent review1 step therapy1 fail first1 or similar requirements applicable to coverage of such item or service under such plan or coverage1 including information regarding utilization management practices and determinations1 including aggregate information related to approval and denial rates1 associated timelines1 and appeals1 as determined appropriate by the ,secretary4 7,c7 ,self-service tool ,for purposes of subparagraph 7,a71 a self-service tool established by a health plan meets the requirements of this subparagraph if such tool-- 7i7 is based on an internet website2 7ii7 provides for real-time responses to requests described in such subparagraph2 7iii7 is updated in a manner such that the information is accurate based on the information available to the plan or coverage at the time the request is made2 7iv7 allows such a request to be made for information with respect to an item or service furnished by-- 7,i7 a specific provider that is an in-network provider with respect to such item or service2 or 7,,ii7 all providers that are in-network providers with respect to such plan or coverage and such item or service2 7v7 provides that such a request may be made for information with respect to an item or service through use of-- 7,i7 the billing code for such item or service2 or 7,,ii7 through use of a descriptive term for such item or service2 and 7vi7 is made available in plain language1 without subscription or other fee4 7,d7 ,nonduplication ,a group health plan or health insurance issuers shall be deemed to be in compliance with this paragraph if such plan or issuer has a tool in place under section #bgii;,a-#d4 7#b7 ,rate and payment information 7,a7 ,in general ,beginning ,january #a of the year that begins on or after the date that is #a year after the date of enactment of the ,patients ,deserve ,price ,tags ,act1 and every quarter thereafter 7if there have been any changes to the rate and payment information described in subparagraphs 7,b7 and 7,c71 each group health plan or health insurance issuer offering coverage in the group or individual market shall make available to the public1 the rate and payment information described in subparagraph 7,b7 in accordance with subparagraph 7,c74 7,b7 ,rate and payment information described ,for purposes of subparagraph 7,a71 the rate and payment information described in this subparagraph is1 with respect to a plan or coverage1 the following3 7i7 ,with respect to each item or service for which benefits are available under such plan or coverage1 excluding those included in clause 7ii71 identified by ,,cpt1 ,,hcpcs1 ,,drg1 or other applicable nationally recognized identifier1 including any applicable code modifiers1 and accompanied by a plain language description of the item or service1 the in-network rate 7expressed as a dollar amount or percentage of charges1 unless otherwise specified by the ,secretary71 including the individual and total amounts for any bundled rates1 in effect as of the date of the submission of such information with each provider 7identified by national provider identifier7 that is an in-network provider with respect to such item or service1 other than such a rate in effect with a provider that an issuer has determined based on factors determined by the ,secretary 7such as medical specialty7 that it is unlikely that the provider would be reimbursed for the item or service4 7ii7 ,with respect to each drug and biologic 7identified by ,national ,drug ,code1 ,j-code1 or other commonly recognized billing code used for drugs7 for which benefits are available under such plan or coverage1 the in-network rate 7expressed as a dollar amount or percentage of charges1 unless otherwise specified by the ,secretary7 in effect as of the first day of the quarter in which such information is made public with each pharmacy or other prescription drug dispenser that is an in-network pharmacy or other prescription drug dispenser with respect to such drug4 7iii7 ,with respect to each item or service for which benefits are available under such plan or coverage 7expressed as a dollar amount71 identified by ,,cpt1 ,,drg1 ,,hcpcs1 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 plan or coverage1 for each such item or service furnished during a representative lookback window established by the ,secretary by each provider that was an out-of-network 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 not fewer than #aa claims for such item or service were submitted to such plan during such period4 7,c7 ,manner of submission ,rate and payment information required to be submitted and made available under this paragraph shall be so submitted and so made available as follows3 7i7 ,information shall be contained in at least #c separate machine-readable files corresponding to the information described in each of clauses 7i7 through 7iii7 of subparagraph 7,b7 that meet such requirements as specified by the ,secretary through rulemaking1 in consultation with the ,secretaries of ,labor and the ,treasury1 to apply comparable requirements to group health plans and health insurance coverage and to entities providing benefit management or other third-party administration services on a contractual basis with a group health plan or coverage4 7ii7 ,requirements specified by the ,secretary through rulemaking 7or subregulatory guidance7 shall ensure the following3 7,i7 ,such files are made available in a widely available format that allows for information contained in such files to be compared across plans and coverage and are freely accessible to individuals at no cost and without the need to establish a user account or provide other credentials4 7,,ii7 ,each such file includes each of the following data elements3 7aa7 ,a numerical identifier for the group health plan or health insurance issuer 7such as a ,health ,insurance ,oversight ,system identifier74 7bb7 ,a plain-language description of the item or service 7including1 for drugs1 the proprietary and nonproprietary name assigned74 7cc7 ,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 7dd7 ,the place of service code4 7ee7 ,the ,national ,provider ,identifier and provider ,tax ,identification ,number4 7iii7 ,the rate and payment information disclosed under clauses 7i7 through 7iii7 of subparagraph 7,b7 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 7iv7 ,an officer or executive of competent authority shall attest to the accuracy and completeness of information submitted and made available under this subparagraph4 ,in the case of a plan or coverage that relies on a third-party administrator or other service provider to compile the information submitted and made available under this subparagraph1 such plan or coverage may satisfy the requirement under this clause by obtaining such an attestation from the third-party administrator or other service provider4 ,such attestation shall be subject to enforcement under paragraph 7#f74 7#c7 ,ownership information ,beginning ,january #a of the year that begins on or after the date that is #a year after the date of enactment of the ,patients ,deserve ,price ,tags ,act1 and every quarter thereafter 7if there have been any changes in the required information71 each group health plan or health insurance issuer offering coverage in the individual or group market shall submit to the ,secretary1 the applicable ,state authority1 and make available to the public1 the name and business address of each person or entity that1 with respect to such plan or coverage-- 7,a7 has an ownership or investment interest2 7,b7 has a controlling interest2 7,c7 is a management services organization2 or 7,d7 is a significant equity investor4 7#d7 ,enforcement 7,a7 ,in general ,each year1 the ,secretary shall audit the machine-readable files required by paragraph 7#b77;,b7 posted by not fewer than #ej group health plans or health insurance issuers for compliance with format and accessibility standards4 7,b7 ,notification and request for corrective action ,in the case of a group health plan or health insurance issuer that fails to comply with the requirements of this paragraph1 not later than #cj days after the date on which the ,secretary determines such failure exists1 the ,secretary shall submit to such plan or issuer a notification of such determination1 which shall include a request for a corrective action plan to comply with such requirements4 7,c7 ,civil monetary penalty ,a plan or issuer that has received a request for a corrective action plan under subparagraph 7,b7 and fails to comply with the requirements of this paragraph by the date that is #cj 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 such health plan or health insurance issuer was failing to comply with such paragraph7 during which such failure was ongoing4 ,such amount shall not exceed #cjj per participant1 beneficiary1 or covered individual per day or #aj1jjj1jjj1 whichever is lesser4 7#e7 ,definitions ,in this subsection3 7,a7 ,in-network provider ,the term in-network provider has the meaning given such term in section #ed4ihae-bgae;,a#a7;a77#b77xii7 of title #bf1 ,code of ,federal ,regulations4 7,b7 ,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#f7 ,rulemaking 7,a7 ,in general ,the ,secretary shall implement this subsection through notice and comment rulemaking in accordance with section #eec of title #e1 ,united ,states ,code4 ,the ,secretary may implement the manner of submission of data described in paragraph 7#b77;,c7 through subregulatory guidance4 7,b7 ,regulations ,regulations promulgated pursuant to this subsection shall provide the following3 7i7 ,the ,secretary shall annually audit the machine-readable files required by paragraph 7#b77;,b7 posted by not fewer than #ej group health plans or health insurance issuers for compliance with format and accessibility standards4 7ii7 ,the ,secretary of ,labor shall annually audit the machine-readable files required by paragraph 7#b77;,b7 posted by not fewer than #bej group health plans or service providers furnishing third-party administrator services to a group health plan for compliance with format and accessibility standards4 7iii7 ,the ,secretary of ,health and ,human ,services1 in conjunction with the ,secretary of ,labor and the ,secretary of the ,treasury1 shall annually issue a report to ,congress that includes findings1 conclusions1 and enforcement actions taken based on audits of the machine-readable files4 ,such report shall be provided no later than ,july #a following the calendar year during which the audits were completed4 ,the ,secretary of ,health and ,human ,services shall make such report to ,congress accessible to the public4 4 7b7 ,effective date 7#a7 ,in general ,the amendments made by subsections 7a7 and 7b7 shall apply beginning ,january #a of the year that begins on or after the date that is #a year after the date of enactment of the ,patients ,deserve ,price ,tags ,act4 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 #gbaeh71 or amendments made to such rule that are applicable before the date of enactment of the ,patients ,deserve ,price ,tags ,act4 #g4 ,increasing group health plan access to health data 7a7 ,group health plan access to information 7#a7 ,in general ,section #bgii;,a-#i of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#aai7 is amended by adding at the end the following3 7#a7 ,group ,health ,plan ,access to ,information 7,a7 ,in general ,no contract or arrangement for services1 and no extension or renewal of such contract or arrangement1 between a group health plan that is offered by a specified large employer or that is a specified large plan 7as such terms are defined in subparagraph 7,f77 and 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 health insurance issuer offering group or individual health insurance coverage1 or pharmacy benefit manager1 or any entity acting as an intermediary between the group health plan and the health care provider1 network association of providers1 service provider offering access to a network or association of providers 7including a licensed health insurance issuer or third-party administrator71 or pharmacy benefit manager 7collectively referred to in this subsection as ,covered ,service ,providers71 is reasonable within the meaning of this subsection unless such contract or arrangement-- 7i7 allows the responsible plan fiduciary 7as that term is defined in section #djh7;b77#b77;,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 subsection 7a77#a77;,b7 to-- 7,i7 comply with applicable law2 and 7,,ii7 determine the accuracy or reasonableness of claims 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 after a request for access by a plan fiduciary 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 data2 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 7,,ix7 limit public disclosure of de-identified or aggregate information2 7,x7 limit the disclosure of1 with respect to a provider that files claims under such plan1 whether a ,covered ,service ,provider-- 7aa7 has an ownership or investment interest2 7bb7 has a controlling interest2 7cc7 is a management services organization2 or 7dd7 is a significant equity investor2 or 7,,xi7 limit the disclosure of the name and address of each person or entity that1 with respect to the health plan service provider-- 7aa7 has an ownership or investment interest2 7bb7 has a controlling interest2 or 7cc7 is a significant equity investor4 7,b7 ,manner of providing information or data 7i7 ,in general ,a ,covered ,service ,provider shall provide information or data under this subsection in a manner consistent with the privacy regulations promulgated under section #acdjb7;a7 of the ,health ,information ,technology for ,economic and ,clinical ,health ,act 7#db ,u4,s4,c4 #agicb7;a77 and consistent with the privacy regulations promulgated under the ,health ,insurance ,portability and ,accountability ,act of #aiif in part #afj and subparts ,a and ,e of part #afd of title #de1 ,code of ,federal ,regulations 7or successor regulations7 7referred to in this paragraph as the ,,hipaa privacy regulations7 and shall restrict the use and disclosure of such information according to such privacy regulations and such ,,hipaa privacy regulations4 ,a ,covered ,service ,provider shall not be required to disclose information or data under this subsection that could reasonably identify a participant or beneficiary through individually identifiable health information 7as such term is defined under ,,hipaa privacy regulations74 7ii7 ,additional requirements ,in carrying out this subsection1 a ,covered ,service ,provider shall comply with section #afd4ejd7;f7 of title #de1 ,code of ,federal ,regulations 7or a successor regulation74 7iii7 ,rule of construction 7,i7 ,in general ,nothing in this subsection shall be construed to modify the requirements for the creation1 receipt1 maintenance1 or transmission of protected health information under the ,,hipaa privacy regulations4 7,,ii7 ,civil rights laws ,nothing in this subsection shall be construed to affect the application of any ,federal or ,state privacy or civil rights law1 including the ,,hipaa privacy regulations1 the ,genetic ,information ,nondiscrimination ,act of #bjjh 7,public ,law #aaj-bcc7 7including the amendments made by such ,act71 the ,americans with ,disabilities ,act of #aiij 7#db ,u4,s4,c4 #abaja et seq471 section #ejd of the ,rehabilitation ,act of #aigc 7#bi ,u4,s4,c4 #gid71 section #aeeg of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahaaf71 title ,,vi of the ,civil ,rights ,act of #aifd 7#db ,u4,s4,c4 #bjjj;d71 and title ,,vii of the ,civil ,rights ,act of #aifd 7#db ,u4,s4,c4 #bjjj;e74 7iv7 ,written notice ,each plan year1 a ,covered ,service ,provider shall provide to each participant or beneficiary written notice informing the participant or beneficiary of the requirement that ,covered ,service ,providers respond to requests to submit information or data under paragraph 7#a71 as applicable1 which may include incorporating such notification in plan documents provided to the participant or beneficiary1 or providing individual notification4 7v7 ,clarification regarding public disclosure of information ,nothing in this subsection shall prevent a ,covered ,service ,provider from placing reasonable restrictions on the public disclosure of the information or data described in paragraph 7#a71 except that such ,provider may not restrict disclosure of such report to the ,department of ,health and ,human ,services1 the ,department of ,labor1 or the ,department of the ,treasury4 7vi7 ,limitation ,this paragraph shall not be construed to abridge or limit the disclosure requirements under this subsection or to impose additional privacy or security requirements on ,covered ,service ,providers or plan sponsors4 7,c7 ,limitation on disclosure ,a group health plan receiving information or data under this subsection may disclose such information only in a manner that is consistent with ,,hipaa 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 ,a group health plan 7and any business associate or other entity acting on behalf of such plan7 may use such information or data only for purposes of plan administration and may not sell1 license1 or otherwise commercially exploit such information or data or provide such information or data to any third party that may take such action4 7,d7 ,requirements of information ,information made available under this subsection 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;,d format or any subsequent standard as established by the ,secretary4 7,,ii7 ,pharmacy claims shall be in the ,national ,council for ,prescription ,drug ,programs 7,,ncpdp7 format or any subsequent standard as established by the ,secretary4 7,,iii7 ,the files shall be unmodified copies of the files sent from the provider1 or1 upon request1 delivered in a machine readable format4 ,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 7or any other format as identified by the ,secretary7 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 payment calculations and formulas1 pricing methodologies1 and other information used to determine the dollar value of reimbursement1 in a format as specified by the ,secretary4 7iv7 ,all non-claim costs shall be itemized and made available to the group health plan as requested through a web-based portal1 through an application program interface 7,,api71 through a downloadable ,comma-,separated ,value 7,,csv7 file1 and1 as appropriate1 through other downloadable machine-readable file types4 7,e7 ,implementation ,the ,secretary shall implement this subsection through notice and comment rulemaking in accordance with section #eec of title #e1 ,united ,states ,code4 7,f7 ,definitions 7i7 ,in general ,the provisions of sections #djh and #daj of the ,employee ,retirement ,income ,security ,act of #aigd shall apply with respect to terms used under this subsection4 7ii7 ,specified large employer ,in this subsection1 the term specified large employer means1 in connection with a group health plan 7including group health insurance coverage offered in connection with such a plan7 established or maintained by a single employer1 with respect to a calendar year or a plan year1 as applicable1 an employer who employed an average of at least #ej employees on business days during the preceding calendar year or plan year and who employs at least #a employee on the first day of the calendar year or plan year4 7iii7 ,specified large plan ,in this subsection1 the term specified large plan means a group health plan 7including group health insurance coverage offered in connection with such a plan7 established or maintained by a plan sponsor described in clause 7ii7 or 7iii7 of section #c7af77;,b7 of the ,employee ,retirement ,income ,security ,act of #aigd that had an average of at least #ej participants on business days during the preceding calendar year or plan year1 as applicable4 4 7#b7 ,civil enforcement 7,a7 ,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 7,a7 ,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 #gbd7;b71 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 up to #aj1jjj for each day during which such violation continues4 ,such penalty shall be in addition to other penalties as may be prescribed by law4 7,b7 ,nothing in subparagraph 7,a7 shall be construed to permit the ,secretary to regulate health care providers acting in their capacity as medical organizations furnishing items and services to patients4 4 7,b7 ,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;b77#a77;,b72 or 7#b7 violates the requirements of section #djh7;b77#b77;,c74 4 7,c7 ,technical amendments ,section #djh7;b77#b77;,b7 of such ,act 7#bi ,u4,s4,c4 #aajh7;b77#b77 is amended-- 7i7 in clause 7i71 by striking this clause and inserting this paragraph2 and 7ii7 by adding at the end the following3 7xi7 ,a contract or arrangement shall not be reasonable under this subparagraph if it fails to comply with section #gbd7;b74 4 7b7 ,updated attestation for price and quality information ,section #bgii;,a-#i7;a77#d7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#aai7;a77#d77 is amended to read as follows3 7#d7 ,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 issuer1 as applicable1 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 ,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 health insurance 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 ,,phsa amendment ,part ,d of title ,,xxvii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#aaa et seq471 as amended by section #fgja7;a7 of the ,consolidated ,appropriations ,act1 #bjbf1 is amended by adding at the end the following3 #bgii;,a-#ab4 ,oversight of administrative service providers 7a7 ,in general ,for plan years beginning on or after ,january #a of the year that begins on or after the date that is #a year after the date of enactment of the ,patients ,deserve ,price ,tags ,act1 no agreement between a group health plan that is offered by a specified large employer or that is a specified large plan 7as such terms are defined in section #bgii;,a-#aa7;f77 or a health insurance issuer offering individual or group health coverage 7that makes an election subject to subsection 7b77#e77 and a health insurance issuer that is operating as a third-party administrator1 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 such group health plans and health insurance issuers in a manner that prevents any health plan service provider from providing the information described in subsection 7b774 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 or the health insurance issuer offering individual or group health insurance coverage the following information at no cost to the plan or issuer3 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 or 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 to its subcontractors in rebates1 fees1 contractual arrangements1 and all other remuneration for administrative and other services4 7,e7 ,all payment data1 calculation methodologies1 and reconciliation information related to alternative compensation arrangements1 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 or issuer related to such arrangements4 7,f7 ,whether1 with respect to a provider that files claims under such plan or coverage1 the health plan service provider-- 7i7 has an ownership or investment interest2 7ii7 has a controlling interest2 7iii7 is a management services organization2 or 7iv7 is a significant equity investor4 7,g7 ,the name and business address for each person or entity that1 with respect to the health plan service provider-- 7i7 has an ownership or investment interest2 7ii7 has a controlling interest2 or 7iii7 is a significant equity investor4 7#b7 ,manner of providing information or data 7,a7 ,in general ,a health plan service provider shall provide information or data under paragraph 7#a7 in a manner consistent with the privacy regulations promulgated under section #acdjb7;a7 of the ,health ,information ,technology for ,economic and ,clinical ,health ,act 7#db ,u4,s4,c4 #agicb7;a77 and consistent with the privacy regulations promulgated under the ,health ,insurance ,portability and ,accountability ,act of #aiif in part #afj and subparts ,a and ,e of part #afd of title #de1 ,code of ,federal ,regulations 7or successor regulations7 7referred to in this paragraph as the ,,hipaa privacy regulations7 and shall restrict the use and disclosure of such information according to such privacy regulations and such ,,hipaa privacy regulations4 7,b7 ,additional requirements ,in carrying out this subsection1 a health plan service provider shall comply with section #afd4ejd7;f7 of title #de1 ,code of ,federal ,regulations 7or a successor regulation74 7,c7 ,rule of construction 7i7 ,in general ,nothing in this subsection shall be construed to modify the requirements for the creation1 receipt1 maintenance1 or transmission of protected health information under the ,,hipaa privacy regulations4 7ii7 ,civil rights laws ,nothing in this subsection shall be construed to affect the application of any ,federal or ,state privacy or civil rights law1 including the ,,hipaa privacy regulations1 the ,genetic ,information ,nondiscrimination ,act of #bjjh 7,public ,law #aaj-bcc7 7including the amendments made by such ,act71 the ,americans with ,disabilities ,act of #aiij 7#db ,u4,s4,c4 #abaja et seq471 section #ejd of the ,rehabilitation ,act of #aigc 7#bi ,u4,s4,c4 #gid71 section #aeeg of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahaaf71 title ,,vi of the ,civil ,rights ,act of #aifd 7#db ,u4,s4,c4 #bjjj;d71 and title ,,vii of the ,civil ,rights ,act of #aifd 7#db ,u4,s4,c4 #bjjj;e74 7,d7 ,written notice ,each plan year1 a health plan service provider shall provide to each participant or beneficiary written notice informing the participant or beneficiary of the requirement for health plan service providers to submit information or data under paragraph 7#a71 as applicable1 which may include incorporating such notification in plan documents provided to the participant or beneficiary1 or providing individual notification4 7,e7 ,clarification regarding public disclosure of information ,nothing in this subsection shall prevent a health plan service provider from placing reasonable restrictions on the public disclosure of the information or data described in paragraph 7#a71 except that such provider may not restrict disclosures under subsection 7b77#a7 to the ,department of ,health and ,human ,services1 the ,department of ,labor1 or the ,department of the ,treasury4 7,f7 ,limitation ,this paragraph shall not be construed to abridge or limit the disclosure requirements under this subsection or to impose additional privacy or security requirements on health plan service providers or plan sponsors4 7#c7 ,disclosure and redisclosure 7,a7 ,in general ,a group health plan or health insurance issuer offering individual or group coverage 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 part #afj and subparts ,a and ,e of part #afd74 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 coverage1 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 ,limitation on use of information ,a group health plan or health insurance issuer 7and any business associate or other entity acting on behalf of such plan7 may use information or data under this paragraph only for purposes of plan administration and may not sell1 license1 or otherwise commercially exploit such information or data or provide such information or data to any third party that may take such action4 7,d7 ,rule of construction ,nothing in this section shall be construed to prevent a group health plan1 a health insurance issuer1 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,e7 ,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 as described in subpart ,k of part #afb 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 or health insurance issuer 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 and operating rules adopted under ,,hipaa at subpart ,p of part #afb 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 7#e7 ,opt-in for health insurance coverage ,in the case of a health insurance issuer offering coverage in the individual or group market1 such issuer may1 on an annual basis1 for plan years beginning on or after the effective date of this section1 elect to require a health plan service provider to submit to such issuer a report that includes all of the information described in paragraph 7#a74 7c7 ,prohibited contractual provisions ,any provision in an agreement that unduly delays or limits a group health plan or 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 issuer 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 7b7 ,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-#ab7;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 7c7 ,,erisa amendments 7#a7 ,in general ,section #ejb7;c7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aacb7;c77 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 #gbg4 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 7#i71 7#ac71 or 7#ad74 #i4 ,state preemption only in event of conflict ,the provisions of section #bgah;,a of the ,public ,health ,service ,act 7as added and amended by this ,act7 shall not be construed to supersede any provision of ,state law which establishes1 implements1 or continues in effect any requirement or prohibition related to health care price transparency1 including for hospitals1 clinical diagnostic laboratories1 provider of specified imaging services1 and ambulatory surgical centers 7as such terms are defined in section #bgah;,a7a7 of the ,public ,health ,service ,act71 except to the extent that such requirement or prohibition prevents the application of a requirement or prohibition of such sections 7or such amendments74 ,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 ,advanced explanation of benefits ,section #bgii;,a-#a7;f7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#aaa7;f77 is amended-- 7#a7 in paragraph 7#a7-- 7,a7 by striking subparagraph 7,c7 and inserting the following3 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 2 and 7,b7 by adding at the end the following 7,i7 ,a notification that the recipient may be held harmless1 in certain circumstances1 if the information in the advanced explanation of benefits does not match the amount the recipient is billed4 2 and 7#b7 by adding at the end the following 7#c7 ,hold harmless 7,a7 ,in general ,for plan years beginning on or after the date that is #a year after the date on which the ,secretary implements this section1 a participant1 beneficiary1 or enrollee shall be held harmless for any amount that is substantially in excess 7as defined by the ,secretary in a manner consistent with the process described in section #bgii;,b-#g7 of the estimate generated by the advanced explanation of benefits4 7,b7 ,no patient responsibility for excess charges ,a group health plan or a health insurance issuer in the group or individual market shall not hold a participant1 beneficiary1 or enrollee responsible for excess charges described in this paragraph if such excess is the result of coverage or payment determinations that differ from projections made in the advanced explanation of benefits at the time such explanation was generated4 7,c7 ,substantial excess ,a participant1 beneficiary1 or enrollee shall not be held harmless for excess amounts if such amounts reflect the cost of medically necessary items or services furnished based on unforeseen circumstances that could not have reasonably been anticipated by the provider or facility at the time the good faith estimate was generated or by the plan or issuer at the time the advanced explanation of benefits was generated4 4 7b7 ,good faith estimates ,section #bgii;,b-#f of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#acf7 is amended-- 7#a7 by striking ,each health care and inserting the following3 7a7 ,in general ,each health care 2 and 7#b7 by adding at the end the following3 7b7 ,hold harmless 7#a7 ,in general ,for plan years beginning on or after the date that is #a year after the date on which the ,secretary implements section #bgii;,a-#a7;f71 if an individual enrolled in a group health plan or health insurance coverage 7and seeks to have a claim for an item or service submitted to such plan or coverage7 is responsible for any amount that is substantially in excess 7as defined by the ,secretary in a manner consistent the process described in section #bgii;,b-#g7 of the estimate generated in the advanced explanation of benefits described in section #bgii;,a-#a7;f7 because the final charges for items and services were substantially in excess of the good faith estimate provided to the plan or coverage under this section1 a provider shall not bill the patient for amounts substantially in excess of the advanced explanation of benefits4 7#b7 ,substantial excess ,an individual seeking to have a claim for an item or service covered by a group health plan or health insurance coverage shall not be held harmless for excess amounts if such amounts reflect the cost of medically necessary items or services furnished based on unforeseen circumstances that could not have reasonably been anticipated by the provider or facility at the time the good faith estimate was generated or by the plan or issuer at the time the advanced explanation of benefits was generated4 4 7c7 ,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 ,january #a of the year that begins on or after the date that is #a year after the date of enactment of the ,patients ,deserve ,price ,tags ,act1 each group health plan1 or a health insurance issuer offering group or individual health insurance coverage shall1 within #de days of receiving the information necessary to decide a claim for payment 7as defined by the ,secretary7 for an item or service under the plan or coverage for which liability under the plan or coverage has been determined1 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 comparison when an advanced explanation of benefits is provided7 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 type of site of each item or service1 including office1 facility1 or emergency room4 7vii7 ,if applicable1 a description of any discrepancies that exist between the services outlined in a patient's advanced explanation of benefits and the explanation of benefits4 7viii7 ,the amount of any facility fee or other patient charges that were added to the final payment amount1 together with a plain language explanation of the fee1 if applicable4 7,c7 ,if the provider or facility is a participating provider or facility with respect to the plan or coverage with respect to the furnishing of such item or service1 the contracted rate under such plan or coverage for such item or service4 7,d7 ,the charges submitted by the provider or facility for each item or service4 7,e7 ,information pertaining to plan type1 as defined the ,secretary4 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 #aa4 ,transparency in billing 7a7 ,in general ,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 ,patient access to complete billing information 7a7 ,requirements 7#a7 ,notice of right of access to itemized bills2 ,in general ,a health care provider or health care facility that requests payment from an individual for providing a health care item or service to the patient shall include with such request a written notice of the individual's right to request an itemized bill as part of the individual's designated record set under section #afd1ebd of title #de1 ,code of ,federal ,regulations 7or a successor regulation74 7#b7 ,required information ,a notice under paragraph 7#a7 shall provide-- 7,a7 a phone number and internet website where an individual can make a request for access to their itemized bill2 7,b7 information about the availability of language-assistance services for individuals with limited ,english proficiency 7,,lep72 and 7,c7 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#c7 ,collections actions 7,a7 ,in general ,a health care provider or health care facility shall not bill or 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#a7 or section #acdje7;e77#d7 of the ,,hitech ,act2 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-#f1 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 ,provider requirement ,if a provider fails to provide a documentation as required under subparagraph 7,a77ii7 in the case of items or services1 the good faith estimate described in such subparagraph with respect to such items or services 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 estimate1 as set forth in section #bgii;,b-#f1 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 7b7 ,standards for accessing itemized bills ,section #acdje7;e7 of the ,,hitech ,act 7#db ,u4,s4,c4 #agice7;e77 is amended-- 7#a7 in paragraph 7#b71 by striking and at the end2 7#b7 in paragraph 7#c71 by striking the period and inserting 2 and2 and 7#c7 by adding at the end1 the following3 7#d7 if the individual makes a request only for an itemized copy of a bill for services provided1 the covered entity or business associate shall-- 7,a7 make such protected health information available within #cj days of such request2 7,b7 not impose any fee for providing such individual a copy of their information2 and 7,c7 include in such itemized bill1 a plain language description of each distinct health care item or service1 all applicable billing codes for each distinct item or service1 including modifiers1 using standard and commonly recognized billing code sets1 the price and billed amount1 if different1 of each distinct item or service4 4 #ab4 ,technical amendments 7a7 ,,erisa ,section #gae7;a77#a7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aahe;d7a77#a77 is amended by inserting and parts ,d and ,e of the ,public ,health ,service ,act 7as amended by the ,patients ,deserve ,price ,tags ,act7 after ,affordable ,care ,act74 7b7 ,internal ,revenue ,code ,section #ihae7;a77#a7 of the ,internal ,revenue ,code of #aihf is amended by inserting and parts ,d and ,e of the ,public ,health ,service ,act 7as amended by the ,patients ,deserve ,price ,tags ,act7 after ,affordable ,care ,act74 #ac4 ,implementation and enforcement funding 7a7 ,appropriation for ,secretary of ,labor ,there are authorized to be appropriated1 such sums as may be necessary for fiscal year #bjbf1 and each subsequent fiscal year1 to enable the ,secretary of ,labor to carry out this ,act and the amendments made by this ,act1 including enforcement activities4 7b7 ,appropriation for the ,secretary of ,health and ,human ,services ,there are authorized to be appropriated1 such sums as may be necessary for fiscal year #bjbf1 and each subsequent fiscal year1 to enable the ,secretary of ,health and ,human ,services to carry out the amendments made by this ,act1 including implementation and enforcement activities4 ,july #bg1 #bjbf,reported with an amendment