,,ii #aaith ,,congress #ast ,session ,s4 #cchi ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,december #i1 #bjbe,mr4 ,marshall introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to lower health care costs for ,americans4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,lowering ,health ,care ,costs for ,americans ,act4 7b7 ,table of contents ,the table of contents for this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4,,title ,i--,general provisions,sec4 #aja4 ,minimum monthly premium payments4,sec4 #ajb4 ,requiring biometric and ,,id verification4,sec4 #ajc4 ,facilitating enrollment in and payment into ,healthcare ,affordability ,accounts4,sec4 #ajd4 ,healthcare ,affordability ,accounts4,sec4 #aje4 ,extension of temporary enhanced premium credits4,sec4 #ajf4 ,special rules relating to coverage of abortion services4,sec4 #ajg4 ,special rules relating to credit for plans covering abortion services4,sec4 #ajh4 ,reporting of health insurance coverage4,sec4 #aji4 ,exclusion of gender transition procedures from coverage under qualified health plans4,sec4 #aaj4 ,funding cost sharing reduction payments4,sec4 #aaa4 ,waivers for ,state innovation4,,title ,,ii--,hospital transparency requirements,sec4 #bja4 ,strengthening hospital price transparency requirements4,sec4 #bjb4 ,increasing price transparency of clinical diagnostic laboratory tests4,sec4 #bjc4 ,imaging transparency4,sec4 #bjd4 ,ambulatory surgical center price transparency requirements4,sec4 #bje4 ,strengthening health coverage transparency requirements4,sec4 #bjf4 ,increasing group health plan access to health data4,sec4 #bjg4 ,oversight of administrative service providers4,sec4 #bjh4 ,state preemption only in event of conflict4,sec4 #bji4 ,requirement for explanation of benefits4,sec4 #baj4 ,provision of itemized bills4 ,i ,general provisions #aja4 ,minimum monthly premium payments 7a7 ,in general ,section #cf;,b7b7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new paragraph3 7#d7 ,limitation ,notwithstanding paragraphs 7#b7 and 7#c71 in no case shall the premium assistance amount with respect to any coverage month exceed the excess 7if any7 of the amount determined under paragraph 7#b77;,a7 over-- 7,a7 in the case of a taxpayer whose household income 7expressed as a percent of the poverty line7 is less than #bjj percent1 #aj1 7,b7 in the case of a taxpayer whose household income 7expressed as a percent of the poverty line7 is not less than #bjj percent1 and less than #cjj percent1 #bj1 7,c7 in the case of a taxpayer whose household income 7expressed as a percent of the poverty line7 is not less than #cjj percent1 and less than #djj percent1 #cj1 and 7,d7 in the case of a taxpayer whose household income 7expressed as a percent of the poverty line7 is not less than #djj percent1 #dj4 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after ,december #ca1 #bjbe4 #ajb4 ,requiring biometric and ,,id verification ,section #adaa7;b77#a7 of ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjha7;b77#a77 is amended-- 7#a7 in subparagraph 7,a71 by striking 2 and and inserting a semicolon2 7#b7 by redesignating subparagraph 7,b7 as subparagraph 7,c72 and 7#c7 by inserting after subparagraph 7,a7 the following3 7,b7 government-issued photo identification for each enrollee over the age of #ah1 and any other documentation as the ,administrator of the ,centers for ,medicare ,medicaid ,services may require for purposes of enrollment verification2 and 4 #ajc4 ,facilitating enrollment in and payment into ,healthcare ,affordability ,accounts 7a7 ,in general ,section #acaa of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjca7 is amended-- 7#a7 in subsection 7b77#a7-- 7,a7 in subparagraph 7,b71 by striking and at the end2 7,b7 by redesignating subparagraph 7,c7 as subparagraph 7,d72 and 7,c7 by inserting after subparagraph 7,b7 the following3 7,c7 in the case of plan years beginning after ,december #ca1 #bjbf1 and before ,january #a1 #bjcb1 facilitates enrollment in ,healthcare ,affordability ,accounts described in section #bbc7;i7 of the ,internal ,revenue ,code of #aihf1 for qualified individuals who purchase qualified health plans and are eligible for premium tax credits under section #cf;,b2 and 2 7#b7 by adding at the end of subsection 7c7 the following3 7#h7 ,enrollment in ,healthcare ,affordability ,accounts ,the ,secretary shall establish a procedure for notifying qualified individuals who purchase qualified health plans and who are eligible for a premium tax credit under section #cf;,b of the ,internal ,revenue ,code of #aihf of the need to enroll in a ,healthcare ,affordability ,account described in section #bbc7;i7 of such ,code1 in order to receive such credit1 for plan years beginning after ,december #ca1 #bjbf1 and before ,january #a1 #bjcb4 2 and 7#c7 in subsection 7d77#d77;,g71 by inserting 1 and1 for plan years beginning after ,december #ca1 #bjbf1 and before ,january #a1 #bjcb1 make available to any individual qualifying for such a tax credit1 a link to the application on the website of the ,department of the ,treasury for enrollment in a ,healthcare ,affordability ,account described in section #bbc7;i7 of the ,internal ,revenue ,code of #aihf before the semicolon at the end4 7b7 ,payment of premium tax credits into ,healthcare ,affordability ,accounts ,section #adab of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjhb7 is amended-- 7#a7 in subsection 7a77#c7-- 7,a7 by striking the ,secretary of the ,treasury makes advance payments and inserting 8the ,secretary of the ,treasury-- 7,a7 except as provided in subparagraph 7,b71 makes advance payments 2 7,b7 by striking the period at the end and inserting 1 and2 and 7,c7 by adding at the end the following new subparagraph3 7,b7 in the case of a plan year beginning after ,december #ca1 #bjbf1 and before ,january #a1 #bjcb1 makes advance payments-- 7i7 of such premium tax credit into the ,healthcare ,affordability ,account maintained under section #bbc7;i7 of the ,internal ,revenue ,code of #aihf for each individual eligible for such credit2 and 7ii7 of such cost-sharing reductions to the issuers of the qualified health plans in order to reduce the premiums payable by individuals eligible for such cost-sharing reductions4 2 and 7#b7 in subsection 7c77#b7-- 7,a7 by striking ,the ,secretary and inserting ,except as provided in subparagraph 7,c71 the ,secretary2 and 7,b7 by adding at the end the following new subparagraph3 7,c7 ,payment of premium tax credit into ,healthcare ,affordability ,accounts ,in the case of plan years beginning after ,december #ca1 #bjbf1 and before ,january #a1 #bjca1 the ,secretary of the ,treasury shall make the advance payment under this section of any premium tax credit allowed under section #cf;,b of the ,internal ,revenue ,code of #aihf to the ,healthcare ,affordability ,account of the applicable individual on a monthly basis 7or such other periodic basis as the ,secretary may provide74 4 #ajd4 ,healthcare ,affordability ,accounts 7a7 ,in general ,section #bbc of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new subsection3 7i7 ,healthcare ,affordability ,accounts ,for purposes of this section-- 7#a7 ,in general ,in the case of a ,healthcare ,affordability ,account1 this section shall be applied as provided in paragraphs 7#c7 through 7#g74 7#b7 ,healthcare ,affordability ,account ,the term ,healthcare ,affordability ,account means a health savings account1 determined as provided in this subsection4 7#c7 ,treatment of transferred contributions ,amounts transferred to a ,healthcare ,affordability ,account pursuant to section #adab of the ,patient ,protection and ,affordable ,care ,act shall not be taken into account in determining the deduction allowed by subsection 7a74 7#d7 ,account must be only ,,hsa of individual 7,a7 ,in general ,an individual who has a ,healthcare ,affordability ,account shall not be treated as an eligible individual with respect to any health savings account other than such ,healthcare ,affordability ,account4 7,b7 ,rollover of existing account permitted ,an individual on whose behalf a ,healthcare ,affordability ,account is established may roll over the balance of any other health savings account of the individual to such ,healthcare ,affordability ,account according to the rules of subsection 7f77#e74 7#e7 ,no rollovers permitted ,except as provided in paragraph 7#d77;,b71 subsection 7f77#e7 shall not apply and no amount shall be contributed from a ,healthcare ,affordability ,account to any health savings account other than a ,healthcare ,affordability ,account4 7#f7 ,restriction on use of amounts ,no amounts in a ,healthcare ,affordability ,account may be used to pay for any-- 7,a7 gender transition procedures1 or 7,b7 abortion4 7#g7 ,definitions ,for purposes of paragraph 7#f7-- 7,a7 ,gender transition procedure 7i7 ,in general ,the term gender transition procedure means any hormonal or surgical intervention for the purpose of gender transition1 including-- 7,i7 gonadotropin-releasing hormone 7,gn,r,h7 agonists or other puberty-blocking or suppressing drugs to stop or delay normal puberty2 7,,ii7 testosterone1 estrogen1 progesterone1 or other androgens to an individual at doses that are supraphysiologic to what would normally be produced endogenously in a healthy individual of the same age and sex2 7,,iii7 castration2 7,,iv7 orchiectomy2 7,v7 scrotoplasty2 7,,vi7 implantation of erection or testicular prostheses2 7,,vii7 vasectomy2 7,,viii7 hysterectomy2 7,,ix7 oophorectomy2 7,x7 ovariectomy2 7,,xi7 reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty2 7,,xii7 metoidioplasty2 7,,xiii7 penectomy2 7,,xiv7 phalloplasty2 7,,xv7 vaginoplasty2 7,,xvi7 clitoroplasty2 7,,xvii7 vaginectomy2 7,,xviii7 vulvoplasty2 7,,xix7 reduction thyrochondroplasty2 7,,xx7 chondrolaryngoplasty2 7,,xxi7 mastectomy2 7,,xxii7 tubal ligation2 7,,xxiii7 sterilization2 7,,xxiv7 any plastic1 cosmetic1 or aesthetic surgery that feminizes or masculinizes the facial or other physiological features of an individual2 7,,xxv7 any placement of chest implants to create feminine breasts2 7,,xxvi7 any placement of fat or artificial implants in the gluteal region2 7,,xxvii7 augmentation mammoplasty2 7,,xxviii7 liposuction2 7,,xxix7 lipofilling2 7,,xxx7 voice surgery2 7,,xxxi7 hair reconstruction2 7,,xxxii7 pectoral implants2 and 7,,xxxiii7 the removal of any otherwise healthy or non-diseased body part or tissue4 7ii7 ,exclusions ,the term gender transition procedure does not include the following when furnished to an individual by a health care provider with the consent of such individual or1 if applicable1 such individual's parents or legal guardian3 7,i7 ,services to individuals born with a medically verifiable disorder of sex development1 including an individual with external sex characteristics that are irresolvably ambiguous1 such as an individual born with #df ,,xx chromosomes with virilization1 an individual born with #df ,,xy chromosomes with undervirilization1 or an individual born having both ovarian and testicular tissue4 7,,ii7 ,services provided when a physician has otherwise diagnosed a disorder of sexual development in which the physician has determined through genetic or biochemical testing that the individual does not have normal sex chromosome structure1 sex steroid hormone production1 or sex steroid hormone action for a healthy individual of the same sex and age4 7,,iii7 ,the treatment of any infection1 injury1 disease1 or disorder that has been caused by or exacerbated by the performance of gender transition procedures1 whether or not the gender transition procedure was performed in accordance with ,state and ,federal law or whether or not funding for the gender transition procedure is permissible under this section4 7,,iv7 ,any procedure undertaken because the individual suffers from a physical disorder1 physical injury1 or physical illness 7but not mental1 behavioral1 or emotional distress or a mental1 behavioral1 or emotional disorder7 that would1 as certified by a physician1 place the individual in imminent danger of death or impairment of major bodily function1 unless the procedure is performed4 7,v7 ,puberty suppression or blocking prescription drugs for the purpose of normalizing puberty for a minor experiencing precocious puberty4 7,,vi7 ,male circumcision4 7,b7 ,gender transition ,the term gender transition means the process in which an individual goes from identifying with or presenting as his or her sex to identifying with or presenting a self-proclaimed identity that does not correspond with or is different from his or her sex1 and may be accompanied with social1 legal1 or physical changes4 7,c7 ,sex ,the term sex1 when referring to an individual's sex1 means to refer to either male or female1 as biologically determined4 7,d7 ,female ,the term female1 when used to refer to a natural person1 means an individual who naturally has1 had1 will have1 or would have1 but for a congenital anomaly1 historical accident1 or intentional or unintentional disruption1 the reproductive system that at some point produces1 transports1 and utilizes eggs for fertilization4 7,e7 ,male ,the term male1 when used to refer to a natural person1 means an individual who naturally has1 had1 will have1 or would have1 but for a congenital anomaly1 historical accident1 or intentional or unintentional disruption1 the reproductive system that at some point produces1 transports1 and utilizes sperm for fertilization4 7,f7 ,abortion 7i7 ,in general ,the term abortion means-- 7,i7 drugs or procedures used with the primary intent to end the life of the human being in the womb1 7,,ii7 pre-viable delivery not described in clause 7ii71 and 7,,iii7 post-viable delivery with intentional death of the fetus4 7ii7 ,exclusions ,such term does not include-- 7,i7 separation of the mother and her embryo or fetus to prevent the mother's death or immediate irreversible bodily harm1 which cannot be mitigated in any other way1 7,,ii7 treatment of ectopic or molar pregnancy1 7,,iii7 treatment of miscarriage1 or 7,,iv7 any service described in clause 7i7 in the case of a pregnancy which is the result of an act of rape or incest4 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after ,december #ca1 #bjbf4 #aje4 ,extension of temporary enhanced premium credits 7a7 ,in general ,clause 7iii7 of section #cf;,b7b77#c77;,a7 of the ,internal ,revenue ,code of #aihf is amended-- 7#a7 by striking ,january #a1 #bjbf and inserting ,january #a1 #bjcb1 and 7#b7 by striking #bjbe in the heading and inserting #bjca4 7b7 ,household income limitation ,section #cf;,b7c77#a77;,e7 of the ,internal ,revenue ,code of #aihf is amended-- 7#a7 by striking rule for #bjba through #bjbe4--;,in the case of and inserting the following3 8rules for #bjba through #bjca4-- 7i7 ,in general ,in the case of 1 and 7#b7 by adding at the end the following new clause3 7ii7 ,special rule for #bjbg through #bjca ,in the case of any taxable year beginning after ,december #ca1 #bjbf1 and before ,january #a1 #bjcb1 subparagraph 7,a7 shall be applied by substituting #gjj percent for #djj percent4 4 7c7 ,phasedown of enhanced amounts ,subparagraph 7,a7 of section #cf;,b7b77#c7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new clause3 7iv7 ,phasedown of enhanced amounts 7,i7 ,in general ,in the case of a taxable year beginning after ,december #ca1 #bjbg1 the premium assistance amount determined under this subsection 7without regard to this clause7 shall be reduced by an amount equal to the phasedown percentage of the enhanced amount4 7,,ii7 ,enhanced amount ,for purposes of subclause 7,i71 the term enhanced amount means the excess1 if any1 of the premium assistance amount determined under this subsection 7without regard to this clause7 over the premium assistance amount which would be so determined if clause 7iii7 did not apply for the taxable year4 7,,iii7 ,phasedown percentage ,for purposes of subclause 7,i71 the phasedown percentage is-- 7aa7 #bj percent1 in the case of a taxable year beginning after ,december #ca1 #bjbg1 and before ,january #a1 #bjbi1 7bb7 #dj percent1 in the case of a taxable year beginning after ,december #ca1 #bjbh1 and before ,january #a1 #bjcj1 7cc7 #fj percent1 in the case of a taxable year beginning after ,december #ca1 #bjbi1 and before ,january #a1 #bjca1 and 7dd7 #hj percent1 in the case of a taxable year beginning after ,december #ca1 #bjcj1 and before ,january #a1 #bjcb4 4 7d7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjbe4 #ajf4 ,special rules relating to coverage of abortion services 7a7 ,in general ,section #acjc7;b7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjbc7;b77 is amended-- 7#a7 in paragraph 7#b7-- 7,a7 by amending subparagraph 7,a7 to read as follows3 7,a7 ,prohibition on the use of ,federal funds ,if a qualified health plan provides coverage of services described in paragraph 7#a77;,b77i71 the issuer of the plan shall not use any amount attributable to any cost-sharing reduction under section #adjb of the ,patient ,protection and ,affordable ,care ,act 7and the amount 7if any7 of the advance payment of the reduction under section #adab74 2 7,b7 in subparagraph 7,b77i77,i71 by striking credits and cost-sharing reductions described in subparagraph 7,a7 and inserting cost-sharing reductions described in subparagraph 7,a7 and premium tax credits under section #cf;,b of the ,internal ,revenue ,code of #aihf1 and the amount1 if any1 of the advance payment of such credit under section #adab2 and 7#b7 by amending paragraph 7#c7 to read as follows3 7#c7 ,rules relating to notice 7,a7 ,notice ,a qualified health plan that provides for coverage of the services described in paragraph 7#a77;,b77i7 shall1 at the time of enrollment1 provide notice to enrollees-- 7i7 that the plan includes such coverage2 7ii7 the amount of the premium charged for such coverage2 and 7iii7 that such amount is not eligible for the premium tax credit under section #cf;,b of the ,internal ,revenue ,code of #aihf4 7,b7 ,disclosures 7i7 ,in general ,the issuer of a plan described in subparagraph 7,a7 shall include the coverage of services described in paragraph 7#a77;,b77i7 as part of the summary of benefits and coverage explanation for the plan1 as applicable4 7ii7 ,comparative information ,if one or more plans described in subparagraph 7,a7 are offered through an ,exchange in a ,state1 the ,exchange shall include in any standardized format for presenting health benefits plan options to potential enrollees1 comparative information on plan coverage of such services4 4 7b7 ,effective date ,the amendments made by subsection 7a7 shall apply with respect to plan years beginning after ,december #ca1 #bjbf4 #ajg4 ,special rules relating to credit for plans covering abortion services 7a7 ,in general ,paragraph 7#c7 of section #cf;,b7b7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new subparagraph3 7,f7 ,special rule for abortion coverage ,if a qualified health plan offers coverage of abortion 7as defined in section #bbc7;i77#g77;,f771 the portion of the premium for the plan properly allocable 7under rules prescribed by the ,secretary of ,health and ,human ,services7 to such coverage shall not be taken into account in determining either the monthly premium or the adjusted monthly premium under paragraph 7#b74 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after ,december #ca1 #bjbf4 #ajh4 ,reporting of health insurance coverage 7a7 ,in general ,subclause 7,,ii7 of section #fjee7;b77#a77;,b77iii7 of the ,internal ,revenue ,code of #aihf is amended to read as follows3 7,,ii7 in the case of a qualified health plan-- 7aa7 the amount of the plan premium1 7bb7 if the plan provided coverage of services described in subsection 7b77#a7 of section #acjc of the ,patient ,protection and ,affordable ,care ,act1 the amount of the plan premium attributable to such coverage 7calculated as described in subsection 7b77#b77;,b7 of such section71 and 7cc7 the amount 7if any7 of any advance payment under section #adab of the ,patient ,protection and ,affordable ,care ,act of any premium tax credit under section #cf;,b with respect to such coverage1 and 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after ,december #ca1 #bjbf4 #aji4 ,exclusion of gender transition procedures from coverage under qualified health plans 7a7 ,in general ,section #acja7;a77#a7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjba7;a77#a77 is amended-- 7#a7 in subparagraph 7,b71 by striking and after the semicolon2 7#b7 in subparagraph 7,c77iv71 by striking the period at the end and inserting 2 and2 and 7#c7 by adding at the end the following3 7,d7 does not provide coverage for gender transition procedures4 4 7b7 ,definition of gender transition procedure ,section #acja of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjba7 is amended by adding at the end the following3 7c7 ,definitions relating to gender transition procedures 7#a7 ,gender transition procedure 7,a7 ,in general ,for purposes of subsection 7a77#a77;,d71 the term gender transition procedure means any hormonal or surgical intervention for the purpose of gender transition1 including-- 7i7 gonadotropin-releasing hormone 7,gn,r,h7 agonists or other puberty-blocking or suppressing drugs to stop or delay normal puberty2 7ii7 testosterone1 estrogen1 progesterone1 or other androgens to an individual at doses that are supraphysiologic to what would normally be produced endogenously in a healthy individual of the same age and sex2 7iii7 castration2 7iv7 orchiectomy2 7v7 scrotoplasty2 7vi7 implantation of erection or testicular prostheses2 7vii7 vasectomy2 7viii7 hysterectomy2 7ix7 oophorectomy2 7x7 ovariectomy2 7xi7 reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty2 7xii7 metoidioplasty2 7xiii7 penectomy2 7xiv7 phalloplasty2 7xv7 vaginoplasty2 7xvi7 clitoroplasty2 7xvii7 vaginectomy2 7xviii7 vulvoplasty2 7xix7 reduction thyrochondroplasty2 7xx7 chondrolaryngoplasty2 7xxi7 mastectomy2 7xxii7 tubal ligation2 7xxiii7 sterilization2 7xxiv7 any plastic1 cosmetic1 or aesthetic surgery that feminizes or masculinizes the facial or other physiological features of an individual2 7xxv7 any placement of chest implants to create feminine breasts2 7xxvi7 any placement of fat or artificial implants in the gluteal region2 7xxvii7 augmentation mammoplasty2 7xxviii7 liposuction2 7xxix7 lipofilling2 7xxx7 voice surgery2 7xxxi7 hair reconstruction2 7xxxii7 pectoral implants2 and 7xxxiii7 the removal of any otherwise healthy or non-diseased body part or tissue4 7,b7 ,exclusions ,for purposes of subsection 7a77#a77;,d71 the term gender transition procedure does not include the following when furnished to an individual by a health care provider with the consent of such individual or1 if applicable1 such individual's parents or legal guardian3 7i7 ,services to individuals born with a medically verifiable disorder of sex development1 including an individual with external sex characteristics that are irresolvably ambiguous1 such as an individual born with #df ,,xx chromosomes with virilization1 an individual born with #df ,,xy chromosomes with undervirilization1 or an individual born having both ovarian and testicular tissue4 7ii7 ,services provided when a physician has otherwise diagnosed a disorder of sexual development in which the physician has determined through genetic or biochemical testing that the individual does not have normal sex chromosome structure1 sex steroid hormone production1 or sex steroid hormone action for a healthy individual of the same sex and age4 7iii7 ,the treatment of any infection1 injury1 disease1 or disorder that has been caused by or exacerbated by the performance of gender transition procedures1 whether or not the gender transition procedure was performed in accordance with ,state and ,federal law or whether or not funding for the gender transition procedure is permissible under this section4 7iv7 ,any procedure undertaken because the individual suffers from a physical disorder1 physical injury1 or physical illness 7but not mental1 behavioral1 or emotional distress or a mental1 behavioral1 or emotional disorder7 that would1 as certified by a physician1 place the individual in imminent danger of death or impairment of major bodily function1 unless the procedure is performed4 7v7 ,puberty suppression or blocking prescription drugs for the purpose of normalizing puberty for a minor experiencing precocious puberty4 7vi7 ,male circumcision4 7#b7 ,related terms ,for purposes of paragraph 7#a73 7,a7 ,female ,the term female1 when used to refer to a natural person1 means an individual who naturally has1 had1 will have1 or would have1 but for a congenital anomaly1 historical accident1 or intentional or unintentional disruption1 the reproductive system that at some point produces1 transports1 and utilizes eggs for fertilization4 7,b7 ,gender transition ,the term gender transition means the process in which an individual goes from identifying with or presenting as his or her sex to identifying with or presenting a self-proclaimed identity that does not correspond with or is different from his or her sex1 and may be accompanied with social1 legal1 or physical changes4 7,c7 ,male ,the term male1 when used to refer to a natural person1 means an individual who naturally has1 had1 will have1 or would have1 but for a congenital anomaly1 historical accident1 or intentional or unintentional disruption1 the reproductive system that at some point produces1 transports1 and utilizes sperm for fertilization4 7,d7 ,sex ,the term sex1 when referring to an individual's sex1 means to refer to either male or female1 as biologically determined4 4 7c7 ,effective date ,the amendments made by this section shall apply with respect to plan years beginning on or after ,january #a1 #bjbf4 #aaj4 ,funding cost sharing reduction payments ,section #adjb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjga7 is amended by adding at the end the following new subsection3 7h7 ,funding 7#a7 ,in general ,there are appropriated out of any monies in the ,treasury not otherwise appropriated such sums as may be necessary for purposes of making payments under this section for plan years beginning on or after ,january #a1 #bjbf4 7#b7 ,limitation 7,a7 ,in general ,the amounts appropriated under paragraph 7#a7 may not be used for purposes of making payments under this section for a qualified health plan that provides health benefit coverage that includes coverage of abortion4 7,b7 ,exception ,subparagraph 7,a7 shall not apply to payments for a qualified health plan that provides coverage of abortion only if necessary to save the life of the mother or if the pregnancy is a result of an act of rape or incest4 4 #aaa4 ,waivers for ,state innovation 7a7 ,streamlining the ,state application process ,section #accb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjeb7 is amended-- 7#a7 in subsection 7a77#a77;,c71 by striking the law and inserting a law or has in effect a certification2 and 7#b7 in subsection 7b77#b7-- 7,a7 in the paragraph heading1 by inserting or certify after law2 7,b7 in subparagraph 7,a7-- 7i7 by striking ,a law and inserting the following3 7i7 ,laws ,a law 2 and 7ii7 by adding at the end the following3 7ii7 ,certifications ,a certification described in this paragraph is a document1 signed by the ,governor of the ,state1 that certifies that such ,governor has the authority under existing ,federal and ,state law to take action under this section1 including implementation of the ,state plan under subsection 7a77#a77;,b74 2 and 7,c7 in subparagraph 7,b7-- 7i7 in the subparagraph heading1 by striking of opt out2 and 7ii7 by striking may repeal a law and all that follows through the period at the end and inserting the following3 8may terminate the authority provided under the waiver with respect to the ,state by-- 7i7 repealing a law described in subparagraph 7,a77i72 or 7ii7 terminating a certification described in subparagraph 7,a77ii71 through a certification for such termination signed by the ,governor of the ,state4 4 7b7 ,giving ,states more funding flexibility1 ,to establish reinsurance1 invisible high-,risk pools1 insurance stability funds1 and other programs 7#a7 ,state grants under waivers ,section #accb7;a7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjeb7;a77 is amended-- 7,a7 in paragraph 7#c7-- 7i7 in the first sentence-- 7,i7 by inserting or would qualify for a reduced portion of after would not qualify for2 7,,ii7 by inserting 1 or the ,state would not qualify for or would qualify for a reduced portion of basic health program funds under section #acca1 after subtitle ,e2 7,,iii7 by inserting 1 or basic health program funds the ,state would have received1 after this title2 and 7,,iv7 by inserting or for implementing the basic health program established under section #acca before the period2 7ii7 in the second sentence1 by inserting before the period 1 and with respect to participation in the basic health program and funds provided to such other ,states under section #acca2 and 7iii7 by adding after the second sentence the following3 ,a ,state may request that all of1 or any portion of1 such aggregate amount of such credits1 reductions1 or funds be paid to the ,state as described in the first sentence42 7,b7 by redesignating paragraphs 7#d71 7#e71 and 7#f7 as paragraphs 7#e71 7#f71 and 7#g71 respectively2 and 7,c7 by inserting after paragraph 7#c7 the following3 7#d7 ,federal funding for invisible high-risk pool and reinsurance programs 7,a7 ,allocations ,not later than #de days after the date of enactment of the ,lowering ,health ,care ,costs for ,americans ,act1 the ,secretary1 in consultation with the ,national ,association of ,insurance ,commissioners1 shall specify an allocation methodology for determining the amount of funds appropriated under section #b7;a77#b77;,b7 of the ,lowering ,health ,care ,costs for ,americans ,act for a fiscal year to be allocated for each ,state for purposes of subparagraph 7,b7 and section #b7;a77#b77;,c7 of the ,lowering ,health ,care ,costs for ,americans ,act4 7,b7 ,state grants ,from amounts appropriated under section #b7;a77#b77;,b7 of the ,lowering ,health ,care ,costs for ,americans ,act for a fiscal year1 the ,secretary shall award grants to ,states for each of fiscal years #bjbg through #bjcj1 in amounts determined in accordance with the allocation methodology under subparagraph 7,a71 for the following purposes3 7i7 ,for fiscal year #bjbg1 for administrative costs of the ,state associated with preparing and submitting information described in subsection 7a77#a77;,b7 that includes an invisible high-risk pool or reinsurance program that meets the requirements of subsection 7g77#b71 or costs associated with the establishment of such invisible high-risk pool or reinsurance program4 7ii7 ,for each of fiscal years #bjbh1 #bjbi1 and #bjcj1 for the establishment or maintenance of invisible high-risk pools and reinsurance programs that meet the requirements of subsection 7g77#b7 and for which the ,state has received a waiver under this section4 7,c7 ,budget neutrality ,funds awarded to a ,state under a grant awarded under subparagraph 7,b7 shall not be taken into account for purposes of determining under paragraph 7#a7 whether the ,state waiver is budget neutral1 or determining under subsection 7b77#a7 whether the ,state waiver increases the ,federal deficit4 4 7#b7 ,appropriations 7,a7 ,in general ,there are authorized to be appropriated1 and there are appropriated1 to the ,secretary of ,health and ,human ,services1 for the purposes described in section #accb7;a77#d77;,b7 of the ,patient ,protection and ,affordable ,care ,act and subparagraph 7,c71 out of any funds in the ,treasury not otherwise appropriated-- 7i7 #ejj1jjj1jjj for fiscal year #bjbg2 and 7ii7 #e1jjj1jjj1jjj for each of fiscal years #bjbh1 #bjbi1 and #bjcj4 7,b7 ,available until expended ,amounts appropriated under this paragraph shall remain available until expended4 7#c7 ,default ,federal safeguard 7,a7 ,in general ,for purposes of plan year #bjbf1 in the case of a ,state that does not1 by a date specified by the ,secretary of ,health and ,human ,services 7referred to in this paragraph as the ,secretary71 in consultation with the ,national ,association of ,insurance ,commissioners1 have in effect a waiver under section #accb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjeb7 that includes an invisible high-risk pool or reinsurance program that meets the requirements of subsection 7g77#b7 of such section #accb1 the ,secretary shall1 from amounts appropriated under subparagraph 7,b71 use the allocation determined for the ,state under subsection 7a77#d77;,b7 of such section #accb for plan year #bjbf for the purpose described in clause 7ii7 for such ,state4 7,b7 ,required use for market stabilization payments to issuers ,the ,secretary shall use any allocation for a ,state made pursuant to clause 7i7 to provide incentives to appropriate entities to enter into arrangements with the ,state to help stabilize premiums for health insurance coverage in the individual market in such ,state by providing payments to such appropriate entities using payment parameters and a methodology determined by the ,secretary4 7c7 ,ensuring patient access to more flexible health plans ,section #accb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjeb7 is amended-- 7#a7 in subsection 7a77#a77;,c71 by striking subsection 7b77#b7 and inserting subsection 7b77#c72 and 7#b7 in subsection 7b7-- 7,a7 in paragraph 7#a7-- 7i7 in subparagraph 7,b71 by striking at least as affordable and inserting of comparable affordability1 including for low-income individuals1 individuals with serious health needs1 and other vulnerable populations12 and 7ii7 by amending subparagraph 7,d7 to read as follows3 7,d7 7i7 will not increase the ,federal deficit over the term of the waiver2 and 7ii7 will not increase the ,federal deficit over the term of the #aj-year budget plan submitted under subsection 7a77#a77;,b77ii74 2 7,b7 by redesignating paragraph 7#b7 7as amended by paragraph 7#a77 as paragraph 7#c72 and 7,c7 by inserting after paragraph 7#a7 the following3 7#b7 ,budgetary effect 7,a7 ,in general ,in determining whether a ,state plan submitted under subsection 7a7 meets the deficit neutrality requirements of paragraph 7#a77;,d71 the ,secretary may take into consideration the direct budgetary effect of the provisions of such plan on sources of ,federal funding other than the funding described in subsection 7a77#c74 7,b7 ,limitation ,a determination made by the ,secretary under subparagraph 7,a7-- 7i7 shall not be construed to affect any waiver process or standards or terms and conditions in effect on the date of enactment of the ,lowering ,health ,care ,costs for ,americans ,act under title ,,xi1 ,,xviii1 ,,xix1 or ,,xxi of the ,social ,security ,act1 or any other ,federal law relating to the provision of health care items or services2 and 7ii7 shall be made without regard to any changes in policy with respect to any waiver process or provision of health care items or services described in clause 7i74 4 7d7 ,providing expedited approval of ,state waivers ,section #accb7;d7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjeb7;d77 is amended-- 7#a7 in paragraph 7#a7 by striking #ahj and inserting #abj2 and 7#b7 by adding at the end the following3 7#c7 ,expedited determination 7,a7 ,in general ,with respect to any application under subsection 7a77#a7 submitted on or after the date of enactment of the ,lowering ,health ,care ,costs for ,americans ,act or any such application submitted prior to such date of enactment and under review by the ,secretary on such date of enactment1 the ,secretary shall make a determination on such application1 using the criteria for approval otherwise applicable under this section1 not later than #de days after the receipt of such application1 and shall allow the public notice and comment at the ,state and ,federal levels described under subsection 7a77#e7 to occur concurrently if such ,state application-- 7i7 is submitted in response to an urgent situation1 with respect to areas in the ,state that the ,secretary determines are at risk for excessive premium increases or having no health plans offered in the applicable health insurance market for the current or following plan year2 7ii7 is for a waiver that is the same or substantially similar to a waiver that the ,secretary already has approved for another ,state2 or 7iii7 is for a waiver that includes an invisible high-risk pool or reinsurance program described in subparagraph 7,a71 7,b71 or 7,d7 of subsection 7g77#b74 7,b7 ,approval 7i7 ,urgent situations 7,i7 ,provisional approval ,a waiver approved under the expedited determination process under subparagraph 7,a77i7 shall be in effect for a period of #c years1 unless the ,state requests a shorter duration4 7,,ii7 ,full approval ,subject to the requirements for approval otherwise applicable under this section1 not later than #a year before the expiration of a provisional waiver period described in subclause 7,i7 with respect to an application described in subparagraph 7,a77i71 the ,secretary shall make a determination on whether to extend the approval of such waiver for the full term of the waiver requested by the ,state1 for a total approval period not to exceed #f years4 ,the ,secretary may request additional information as the ,secretary determines appropriate to make such determination4 7ii7 ,approval of same or similar applications ,an approval of a waiver under subparagraph 7,a77ii7 shall be subject to the terms of subsection 7e74 7,c7 ,,gao study ,not later than #e years after the date of enactment of the ,lowering ,health ,care ,costs for ,americans ,act1 the ,comptroller ,general of the ,united ,states shall conduct a review of all waivers approved pursuant to subparagraph 7,a77ii7 to evaluate whether such waivers met the requirements of subsection 7b77#a7 and whether the applications should have qualified for such expedited process4 4 7e7 ,providing certainty for ,state-,based reforms ,section #accb7;e7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjeb7;e77 is amended by striking ,no waiver and all that follows through the period at the end and inserting the following3 8,a waiver under this section-- 7#a7 shall be in effect for a period of #f years unless the ,state requests a shorter duration2 7#b7 may be renewed1 subject to the ,state meeting the criteria for approval otherwise applicable under this section1 for unlimited additional #f-year periods upon application by the ,state2 and 7#c7 may not be suspended or terminated1 in whole or in part1 by the ,secretary at any time before the date of expiration of the waiver period 7including any renewal period under paragraph 7#b771 unless the ,secretary determines that the ,state materially failed to comply with the terms and conditions of the waiver4 4 7f7 ,guidance and regulations ,section #accb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjeb7 is amended-- 7#a7 by adding at the end the following3 7f7 ,guidance and regulations 7#a7 ,in general ,with respect to carrying out this section1 the ,secretary shall-- 7,a7 issue guidance1 not later than #fj days after the date of enactment of the ,lowering ,health ,care ,costs for ,americans ,act1 that includes initial examples of model ,state plans that meet the requirements for approval under this section2 and 7,b7 periodically review the guidance issued under subparagraph 7,a7 and1 when appropriate1 issue additional examples of model ,state plans that meet the requirements for approval under this section1 which may include-- 7i7 ,state plans establishing reinsurance or invisible high-risk pool arrangements for purposes of covering the cost of high-risk individuals2 7ii7 ,state plans expanding insurer participation1 access to affordable health plans1 network adequacy1 and health plan options over the entire applicable health insurance market in the ,state2 7iii7 waivers encouraging or requiring health plans in such ,state to deploy value-based insurance designs which structure enrollee cost-sharing and other health plan design elements to encourage enrollees to consume high-value clinical services2 7iv7 ,state plans allowing for significant variation in health plan benefit design2 or 7v7 any other ,state plan as the ,secretary determines appropriate4 7#b7 ,rescission of previous regulations and guidance ,beginning on the date of enactment of the ,lowering ,health ,care ,costs for ,americans ,act1 the regulations promulgated and the guidance issued under this section prior to the date of enactment of the ,lowering ,health ,care ,costs for ,americans ,act shall have no force or effect4 2 and 7#b7 in subsection 7a77#e7 7as redesignated by paragraph 7#b77;,a77ii77-- 7,a7 in subparagraph 7,a71 by inserting 1 as applicable before the period2 and 7,b7 in subparagraph 7,b71 by striking ,not later than #ahj days after the date of enactment of this ,act1 the ,secretary shall and inserting ,the ,secretary may4 7g7 ,invisible high-,risk pools and reinsurance programs ,section #accb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjeb71 as amended by paragraph 7#f71 is further amended by adding at the end the following3 7g7 ,invisible high-,risk pools and reinsurance programs 7#a7 ,funding ,with respect to a ,state that has received a waiver under this section to establish an invisible high-risk pool or reinsurance program described in paragraph 7#b71 the ,state may fund such program1 in whole or in part1 using one or both of the following3 7,a7 ,amounts received through a grant described in subsection 7a77#d77;,b74 7,b7 ,all of1 or a portion of1 the payments made to the ,state as described in subsection 7a77#c71 consistent with the information the ,state provides under subsection 7a77#a77;,b74 7#b7 ,program design ,an invisible high-risk pool or reinsurance program described in this paragraph is a program that meets any of the following3 7,a7 ,an invisible high-risk pool1 as defined by the ,state1 under which health insurance issuers1 with respect to designated individuals who experience higher than average health costs as determined by the ,state1 and are enrolled in health insurance coverage offered in the individual market1 cede risk to the pool1 without affecting the premium paid by the designated individuals or their terms of coverage4 ,with respect to such pool1 the ,state1 or an entity operating the pool on behalf of the ,state1 shall establish-- 7i7 the premium amount the ceding issuer shall pay to the reinsurance pool2 7ii7 the applicable attachment points or coinsurance percentages if the ceding issuer retains any portion of the risk under ceded policies2 and 7iii7 the mechanism by which high-risk individuals are designated for cession to the pool1 which may include a list of designated high-cost health conditions4 7,b7 ,a reinsurance program1 as defined by the ,state1 that assumes a portion of the risk for individuals who experience higher than average health costs1 as determined by the ,state1 in a manner substantially similar to the reinsurance program that operated in the ,state in accordance with section #acda4 7,c7 ,a reinsurance program established by the ,state not otherwise described in this paragraph4 7,d7 ,a program based on another ,state's reinsurance program-- 7i7 described in subparagraph 7,a71 7,b71 or 7,c71 for which an application has been approved under this subsection2 or 7ii7 which was implemented prior to ,september #a1 #bjbe1 and which the ,secretary determines meets the requirements of subparagraph 7,a74 4 7h7 ,applicability ,the amendments made by this ,act to section #accb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjeb7-- 7#a7 with respect to applications for waivers under such section #accb submitted after the date of enactment of this ,act and applications for such waivers submitted prior to such date of enactment and under review by the ,secretary on the date of enactment1 shall take effect on the date of enactment of this ,act2 and 7#b7 with respect to applications for waivers approved under such section #accb before the date of enactment of this ,act1 shall not require reconsideration of whether such applications meet the requirements of such section #accb1 except that1 at the request of a ,state1 the ,secretary shall recalculate the amount of funding provided under subsection 7a77#c7 of such section4 7i7 ,clarifying budget neutrality ,section #accb7;a77#a77;,b7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjeb7;a77#a77;,b77 is amended-- 7#a7 in clause 7i71 by inserting 1 including1 as applicable1 a description of the ,state's plan to use any amounts awarded to the ,state under paragraph 7#d7 to support an invisible high-risk pool or reinsurance program consistent with subsection 7g7 and such information about such program as the ,secretary may require before the semicolon2 and 7#b7 in clause 7ii71 by inserting over both the term of the proposed waiver and the term of the #aj-year budget plan after ,government4 ,,ii ,hospital transparency requirements #bja4 ,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 #bjbf4 7c7 ,continued applicability of state law ,the provisions of this title 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 title4 #bjb4 ,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 #bjc4 ,imaging transparency ,section #bgah of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ah71 as amended by section #bjb1 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 #bjd4 ,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 #bjc1 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 #bje4 ,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 #gbaeh71 before ,january #a1 #bjbf4 #bjf4 ,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 #bjg4 ,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 ,,cfr 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 ,,cfr 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;c7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aacb7;c771 as amended by section #bjf1 is further 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 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;,c71 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;,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 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 7parts #afj and #afd of title #de1 ,code of ,federal ,regulations74 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 ,,cfr 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 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 ,act4 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;a71 of #ajj1jjj per day for each violation of such section1 pursuant to substantially similar processes and procedures as those set forth in subparagraphs 7,d7 through 7,g7 of section #bgbc7;b77#b74 4 #bjh4 ,state preemption only in event of conflict ,the provisions of sections #bja through #bjd 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 #bji4 ,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 #baj4 ,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