Lower Costs, More Transparency Act of 2026

service, the median cash price charged by the hospital (not including charity care) to self-pay individuals for such item or service when provided in such settings for the previous three years, expressed as a dollar amount. ``(iv) With respect to prices made public pursuant to subparagraph (A)(ii), a link to a consumer-friendly document that clearly explains the hospital's charity care policy that includes, if applicable, any sliding scale payment structure employed for determining prices. ``(v) The payer-specific negotiated charges, as applicable, clearly associated with the name of the third party payer and plan and expressed as a dollar amount, that apply to each such item or service when provided in, as applicable, the inpatient setting and outpatient department setting. ``(vi) The de-identified maximum and minimum negotiated charges, as applicable, for each such item or service, not including any such charge that is $0. ``(vii) Any other additional information the Secretary may require (in consultation with stakeholders) for the purpose of improving the accuracy of, or enabling consumers to easily understand and compare, standard charges and prices for an item or service, except information that is duplicative of any other reporting requirement under this subsection. ``(C) Uniform method and format.--Not later than January 1, 2028, the Secretary shall establish a standard, uniform method and format for specified hospitals to use in compiling and making public standard charges pursuant to subparagraph (A)(i) and a standard, uniform method and format for such hospitals to use in compiling and making public prices pursuant to subparagraph (A)(ii). Such methods and formats-- ``(i) shall, in the case of such method and format for making public standard charges pursuant to subparagraph (A)(i), ensure that such charges are made available in a machine- readable format (or a successor technology specified by the Secretary); ``(ii) may be similar to any template made available by the Centers for Medicare & Medicaid Services as of the date of the enactment of this subparagraph; ``(iii) shall meet such standards as determined appropriate by the Secretary in order to ensure the accessibility and usability of such charges and prices; and ``(iv) shall be updated as determined appropriate by the Secretary, in consultation with stakeholders. ``(3) Monitoring compliance.--The Secretary shall establish processes to monitor and assess specified hospitals' compliance with this subsection. Such processes shall include processes relating to the following: ``(A) The evaluation and analysis of complaints made by individuals or other entities relating to such hospitals' compliance with this subsection. ``(B) The use of audits to ensure such hospitals' compliance with this subsection. ``(C) The obtaining of additional information from such hospitals to determine such hospitals' compliance with this subsection (as determined appropriate by the Secretary). ``(4) Enforcement.-- ``(A) In general.--In the case of a specified hospital that fails to comply with the requirements of this subsection-- ``(i) not later than 30 days after the date on which the Secretary determines such failure exists, the Secretary shall submit to such hospital a notification of such determination (which may include, as determined appropriate by the Secretary, a request for a corrective action plan (to be submitted not later than 45 days after such request is made) to comply with such requirements); and ``(ii) in the case of a hospital that does not receive a request for a corrective action plan as part of a notification submitted by the Secretary under clause (i)-- ``(I) the Secretary shall, not later than 60 days after such notification is sent, determine whether such hospital is in compliance with such requirements; and ``(II) if the Secretary determines under subclause (I) that such hospital is not in compliance with such requirements, the Secretary shall either-- ``(aa) submit to such hospital a request for a corrective action plan (to be submitted not later than 45 days after such request is made) to comply with such requirements; or ``(bb) if the Secretary determines that such hospital has not taken meaningful actions to come into compliance since such notification was sent, impose a civil monetary penalty in accordance with subparagraph (B). ``(B) Civil monetary penalty.-- ``(i) In general.--Subject to clause (vii), in addition to any other enforcement actions or penalties that may apply under another provision of Federal law, a specified hospital that has received a request for a corrective action plan under clause (i) or (ii) of subparagraph (A) and fails to comply with the requirements of this subsection by the date that is 90 days after such request is made (or, if such hospital has submitted such a corrective action plan not later than 45 days after the date such request was made, by the date that is 90 days after the date of the submission of such corrective action plan), and a specified hospital with respect to which the Secretary has made a determination described in clause (ii)(II)(bb) of such subparagraph, shall be subject to a civil monetary penalty of an amount specified by the Secretary for each day (beginning with the day on which the Secretary first determined that such hospital was not complying with such requirements) during which such failure was ongoing. Such amount shall not exceed-- ``(I) in the case of a specified hospital with 30 or fewer beds, $300 per day (or, in the case of such a hospital that has been noncompliant with such requirements for a 1-year period or longer, beginning with the first day following such 1-year period, $400 per day); ``(II) in the case of a specified hospital with more than 30 beds but fewer than 101 beds, $12.50 per bed per day (or, in the case of such a hospital that has been noncompliant with such requirements for a 1-year period or longer, beginning with the first day following such 1-year period, $15 per bed per day); ``(III) in the case of a specified hospital with more than 100 beds but fewer than 201 beds, $17.50 per bed per day (or, in the case of such a hospital that has been noncompliant with such requirements for a 1-year period or longer, beginning with the first day following such 1-year period, $20 per bed per day); ``(IV) in the case of a specified hospital with more than 200 beds but fewer than 501 beds, $20 per bed per day (or, in the case of such a hospital that has been noncompliant with such requirements for a 1-year period or longer, beginning with the first day following such 1-year period, $25 per bed per day); and ``(V) in the case of a specified hospital with more than 500 beds, $25 per bed per day (or, in the case of such a hospital that has been noncompliant with such requirements for a 1-year period or longer, beginning with the first day following such 1- year period, $35 per bed per day). ``(ii) Increase authority.--In applying this subparagraph with respect to violations occurring in 2029 or a subsequent year, the Secretary may through notice and comment rulemaking increase-- ``(I) the limitation on the per day amount of any penalty applicable to a specified hospital under clause (i)(I); ``(II) the limitations on the per bed per day amount of any penalty applicable under any of subclauses (II) through (V) of clause (i); and ``(III) the amounts specified in clause (iii)(II). ``(iii) Persistent noncompliance.-- ``(I) In general.--In the case of a specified hospital (other than a specified hospital with 30 or fewer beds) that the Secretary has determined to be knowingly and willfully noncompliant with the provisions of this subsection for two or more 6-month periods during any 3-year period, the Secretary may increase any penalty otherwise applicable under this subparagraph by the amount specified in subclause (II) with respect to such hospital and may require such hospital to complete such additional corrective actions plans as the Secretary may specify. ``(II) Specified amount.--For purposes of subclause (I), the amount specified in this subclause is, with respect to a specified hospital-- ``(aa) with more than 30 beds but fewer than 101 beds, an amount that is not less than $500,000 and not more than $1,000,000; ``(bb) with more than 100 beds but fewer than 301 beds, an amount that is greater than $1,000,000 and not more than $2,000,000; ``(cc) with more than 300 beds but fewer than 501 beds, an amount that is greater than $2,000,000 and not more than $4,000,000; and ``(dd) with more than 500 beds, and amount that is not less than $5,000,000 and not more than $10,000,000. ``(iv) Authority to waive or reduce penalty.-- ``(I) Hospitals located in rural or underserved areas.-- ``(aa) In general.--Subject to item (bb), the Secretary may waive any penalty, or reduce any penalty by not more than 75 percent, otherwise applicable under this subparagraph with respect to a specified hospital located in a rural or underserved area if the Secretary certifies that imposition of such penalty would result in an immediate threat to access to care for individuals in the service area of such hospital. ``(bb) Limitation on application.--The Secretary may not elect to waive a penalty under item (aa) with respect to a specified hospital more than once in a 6-year period and may not elect to reduce such a penalty with respect to such a hospital more than once in such a period. Nothing in the preceding sentence shall be construed as prohibiting the Secretary from both waiving and reducing a penalty with respect to a specified hospital during a 6-year period. ``(II) Reduction if hearing waived.--The Secretary may reduce any penalty otherwise applicable under this subparagraph (as reduced, if applicable, under subclause (I)) by not more than 35 percent if the specified hospital that is the subject of such penalty agrees to waive any right of such hospital to a hearing before an administrative law judge with respect to the imposition of such penalty. ``(v) Hardship exemption.--Notwithstanding any limit on the waiver or reduction of a penalty under clause (iv), the Secretary may waive any penalty with respect to a specified hospital on a case-by-case basis if the Secretary determines that a circumstance exists interfering with such hospital's ability to comply with the provisions of this subsection (such as a natural disaster (as defined in section 602(a) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act), a public health emergency, or other similar or unexpected catastrophe or similar situation). ``(vi) Provision of technical assistance.-- The Secretary shall, to the extent practicable, provide technical assistance relating to compliance with the provisions of this subsection to specified hospitals requesting such assistance. ``(vii) Application of certain provisions.--The provisions of section 1128A (other than subsections (a) and (b) of such section) 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 (a) of such section. ``(viii) Nonduplication of certain penalties.-- ``(I) In general.--The Secretary may not subject a specified hospital to a civil monetary penalty under this subparagraph with respect to noncompliance with the provisions of this subsection for a period if the Secretary has imposed a civil monetary penalty on such hospital under section 2718(f) of the Public Health Service Act for failure to comply with the provisions of such section for such period. ``(II) Prioritization.--In the case of a hospital that the Secretary determines to be in violation of the provisions of this subsection and of section 2718(f) of the Public Health Service Act, the Secretary shall impose penalties as prescribed in such section 2718(f) in lieu of any penalties prescribed in this subsection. ``(C) Publication of hospital price transparency information.--Beginning on January 1, 2028, the Secretary shall make publicly available on the public website of the Centers for Medicare & Medicaid Services information with respect to compliance with the requirements of this subsection and enforcement activities undertaken by the Secretary under this subsection. Such information shall be updated in real time (if practicable) and include-- ``(i) the number of reviews of compliance with this subsection undertaken by the Secretary; ``(ii) the number of notifications described in subparagraph (A)(i) sent by the Secretary; ``(iii) the identity of each specified hospital that was sent such a notification and a description of the nature of such hospital's noncompliance with this subsection; ``(iv) the amount of any civil monetary penalty imposed on such hospital under subparagraph (B); ``(v) whether such hospital subsequently came into compliance with this subsection; ``(vi) any waivers or reductions of penalties made pursuant to a certification by the Secretary under subparagraph (B)(iv), including-- ``(I) the name of any specified hospital that received such a waiver or reduction; ``(II) the dollar amount of each such penalty so waived or reduced; and ``(III) the rationale for the granting of each such waiver or reduction, but only to the extent that such rationale does not make public commercially sensitive information; and ``(vii) any other information as determined by the Secretary. ``(b) Ensuring Accessibility Through Implementation.--In implementing this section, the Secretary shall through rulemaking ensure that a hospital making public charges and prices pursuant to this section takes reasonable steps (as specified by the Secretary) to ensure the accessibility of such charges and information to individuals with limited English proficiency. Such steps may include the hospital's provision of interpretation services or the hospital's provision of translations of charges and information. ``(c) Definitions.--For purposes of this section: ``(1) Discounted cash price.--The term `discounted cash price' means the charge that applies to an individual who pays cash, or cash equivalent, for an item or service. ``(2) Gross charge.--The term `gross charge' means the charge for an individual item or service that is reflected on a specified hospital's chargemaster or provider of service or supplier's, as applicable, chargemaster (or similar list of prices), absent any discounts. ``(3) 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 service. ``(4) 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 service. ``(5) Specified hospital.--The term `specified hospital' means a hospital (as defined in section 1861(e)), a critical access hospital (as defined in section 1861(mmm)(1)), or a rural emergency hospital (as defined in section 1861(kkk)). ``(6) Third party payer.--The term `third party payer' means an entity that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.''. (2) Rule of construction.--Nothing in the amendments made by this subsection may be construed to impede, prohibit, or prevent the Secretary of Health and Human Services from implementing, executing, carrying out, or enforcing the requirements of section 2718(f) of the Public Health Service Act. (b) PHSA.-- (1) In general.--Section 2718 of the Public Health Service Act (42 U.S.C. 300gg-18) is amended by adding at the end the following new subsection: ``(f) Hospital Transparency Requirement.-- ``(1) In general.--Beginning January 1, 2028, each hospital operating within the United States (including a specified hospital (as defined in section 1899D of the Social Security Act)) shall comply with the price transparency requirement described in paragraph (2). ``(2) Requirement described.-- ``(A) In general.--For purposes of paragraph (1), the price transparency requirement described in this paragraph is, with respect to a hospital, that such hospital, in accordance with a method and format established by the Secretary under subparagraph (C), compile and make public (without subscription and free of charge) for each year-- ``(i) all of the hospital's standard charges (including the information described in subparagraph (B)) for each item and service furnished by such hospital; ``(ii) information in a consumer-friendly format (as specified by the Secretary)-- ``(I) on the hospital's prices (including the information described in subparagraph (B)) for as many of the Centers for Medicare & Medicaid Services-specified shoppable services that are furnished by the hospital, and as many additional hospital-selected shoppable services (or all such additional services, if such hospital furnishes fewer than 300 shoppable services) as may be necessary for a combined total of at least 300 shoppable services; and ``(II) that includes, with respect to each Centers for Medicare & Medicaid Services-specified shoppable service that is not furnished by the hospital, an indication that such service is not so furnished; ``(iii) each type 2 national provider identifier associated with the hospital or a unit of the hospital; and ``(iv) an attestation that all information made public pursuant to this subparagraph is complete and accurate. ``(B) Information described.--For purposes of subparagraph (A), the information described in this subparagraph is, with respect to standard charges and prices, as applicable, made public by a hospital, the following: ``(i) A plain language description (as specified by the Secretary) of each item or service, accompanied by, as applicable, the Healthcare Common Procedure Coding System code, the diagnosis-related group, the national drug code, current procedure terminology codes, or other identifier used or approved by the Centers for Medicare & Medicaid Services. ``(ii) The gross charge, as applicable, expressed as a dollar amount (as specified by the Secretary), for each such item or service, when provided in, as applicable, the inpatient setting and outpatient department setting. ``(iii) For each such item or service when provided in, as applicable, the inpatient and outpatient department settings-- ``(I) the discounted cash price, as applicable, expressed as a dollar amount; or ``(II) in the case no discounted cash price is available for such item or service, the median cash price charged by the hospital (not including charity care) to self-pay individuals for such item or service when provided in such settings for the previous three years, expressed as a dollar amount. ``(iv) With respect to prices made public pursuant to subparagraph (A)(ii), a link to a consumer-friendly document that clearly explains the hospital's charity care policy that includes, if applicable, any sliding scale payment structure employed for determining prices. ``(v) The payer-specific negotiated charges, as applicable, clearly associated with the name of the third party payer and plan and expressed as a dollar amount, that apply to each such item or service when provided in, as applicable, the inpatient setting and outpatient department setting. ``(vi) The de-identified maximum and minimum negotiated charges, as applicable, for each such item or service, not including any such charge that is $0. ``(vii) Any other additional information the Secretary may require (in consultation with stakeholders) for the purpose of improving the accuracy of, or enabling consumers to easily understand and compare, standard charges and prices for an item or service, except information that is duplicative of any other reporting requirement under this subsection. ``(C) Uniform method and format.--Not later than January 1, 2028, the Secretary shall establish a standard, uniform method and format for hospitals to use in compiling and making public standard charges pursuant to subparagraph (A)(i) and a standard, uniform method and format for such hospitals to use in compiling and making public prices pursuant to subparagraph (A)(ii). Such methods and formats-- ``(i) shall, in the case of such method and format for making public standard charges pursuant to subparagraph (A)(i), ensure that such charges are made available in a machine- readable format (or a successor technology specified by the Secretary); ``(ii) may be similar to any template made available by the Centers for Medicare & Medicaid Services as of the date of the enactment of this subparagraph; ``(iii) shall meet such standards as determined appropriate by the Secretary in order to ensure the accessibility and usability of such charges and prices; and ``(iv) shall be updated as determined appropriate by the Secretary, in consultation with stakeholders. ``(3) Monitoring compliance.--The Secretary shall establish processes to monitor and assess specified hospitals' compliance with this subsection. Such processes shall include processes relating to the following: ``(A) The evaluation and analysis of complaints made by individuals or other entities relating to such hospitals' compliance with this subsection. ``(B) The use of audits to ensure such hospitals' compliance with this subsection. ``(C) The obtaining of additional information from such hospitals to determine such hospitals' compliance with this subsection (as determined appropriate by the Secretary). ``(4) Enforcement.-- ``(A) In general.--In the case of a hospital that fails to comply with the requirements of this subsection-- ``(i) not later than 30 days after the date on which the Secretary determines such failure exists, the Secretary shall submit to such hospital a notification of such determination (which may include, as determined appropriate by the Secretary, a request for a corrective action plan (to be submitted not later than 45 days after such request is made) to comply with such requirements); and ``(ii) in the case of a hospital that does not receive a request for a corrective action plan as part of a notification submitted by the Secretary under clause (i)-- ``(I) the Secretary shall, not later than 60 days after such notification is sent, determine whether such hospital is in compliance with such requirements; and ``(II) if the Secretary determines under subclause (I) that such hospital is not in compliance with such requirements, the Secretary shall either-- ``(aa) submit to such hospital a request for a corrective action plan (to be submitted not later than 45 days after such request is made) to comply with such requirements; or ``(bb) if the Secretary determines that such hospital has not taken meaningful actions to come into compliance since such notification was sent, impose a civil monetary penalty in accordance with subparagraph (B). ``(B) Civil monetary penalty.-- ``(i) In general.--In addition to any other enforcement actions or penalties that may apply under another provision of Federal law, a hospital that has received a request for a corrective action plan under clause (i) or (ii) of subparagraph (A) and fails to comply with the requirements of this subsection by the date that is 90 days after such request is made (or, if such hospital has submitted such a corrective action plan not later than 45 days after the date such request was made, by the date that is 90 days after the date of the submission of such corrective action plan), and a hospital with respect to which the Secretary has made a determination described in clause (ii)(II)(bb) of such subparagraph, shall be subject to a civil monetary penalty of an amount specified by the Secretary for each day (beginning with the day on which the Secretary first determined that such hospital was not complying with such requirements) during which such failure was ongoing. Such amount shall not exceed-- ``(I) in the case of a hospital with 30 or fewer beds, $300 per day (or, in the case of such a hospital that has been noncompliant with such requirements for a 1-year period or longer, beginning with the first day following such 1-year period, $400 per bed per day); ``(II) in the case of a hospital with more than 30 beds but fewer than 101 beds, $12.50 per bed per day (or, in the case of such a hospital that has been noncompliant with such requirements for a 1-year period or longer, beginning with the first day following such 1-year period, $15 per bed per day); ``(III) in the case of a hospital with more than 100 beds but fewer than 201 beds, $17.50 per bed per day (or, in the case of such a hospital that has been noncompliant with such requirements for a 1-year period or longer, beginning with the first day following such 1-year period, $20 per bed per day); ``(IV) in the case of a hospital with more than 200 beds but fewer than 501 beds, $20 per bed per day (or, in the case of such a hospital that has been noncompliant with such requirements for a 1-year period or longer, beginning with the first day following such 1-year period, $25 per bed per day); and ``(V) in the case of a hospital with more than 500 beds, $25 per bed per day (or, in the case of such a hospital that has been noncompliant with such requirements for a 1-year period or longer, beginning with the first day following such 1-year period, $35 per bed per day). ``(ii) Increase authority.--In applying this subparagraph with respect to violations occurring in 2029 or a subsequent year, the Secretary may through notice and comment rulemaking increase-- ``(I) the limitation on the per day amount of any penalty applicable to a hospital under clause (i)(I); ``(II) the limitations on the per bed per day amount of any penalty applicable under any of subclauses (II) through (V) of clause (i); and ``(III) the amounts specified in clause (iii)(II). ``(iii) Persistent noncompliance.-- ``(I) In general.--In the case of a hospital (other than a hospital with 30 or fewer beds) that the Secretary has determined to be knowingly and willfully noncompliant with the provisions of this subsection for two or more 6-month periods during any 3- year period, the Secretary may increase any penalty otherwise applicable under this subparagraph by the amount specified in subclause (II) with respect to such hospital and may require such hospital to complete such additional corrective actions plans as the Secretary may specify. ``(II) Specified amount.--For purposes of subclause (I), the amount specified in this subclause is, with respect to a hospital-- ``(aa) with more than 30 beds but fewer than 101 beds, an amount that is not less than $500,000 and not more than $1,000,000; ``(bb) with more than 100 beds but fewer than 301 beds, an amount that is greater than $1,000,000 and not more than $2,000,000; ``(cc) with more than 300 beds but fewer than 501 beds, an amount that is greater than $2,000,000 and not more than $4,000,000; and ``(dd) with more than 500 beds, and amount that is not less than $5,000,000 and not more than $10,000,000. ``(iv) Authority to waive or reduce penalty.-- ``(I) Hospitals located in rural or underserved areas.-- ``(aa) In general.--Subject to item (bb), the Secretary may waive any penalty, or reduce any penalty by not more than 75 percent, otherwise applicable under this subparagraph with respect to a hospital located in a rural or underserved area if the Secretary certifies that imposition of such penalty would result in an immediate threat to access to care for individuals in the service area of such hospital. ``(bb) Limitation on application.--The Secretary may not elect to waive a penalty under item (aa) with respect to a hospital more than once in a 6-year period and may not elect to reduce such a penalty with respect to such a hospital more than once in such a period. Nothing in the preceding sentence shall be construed as prohibiting the Secretary from both waiving and reducing a penalty with respect to a hospital during a 6-year period. ``(II) Reduction if hearing waived.--The Secretary may reduce any penalty otherwise applicable under this subparagraph (as reduced, if applicable, under subclause (I)) by not more than 35 percent if the specified hospital that is subject of such penalty agrees to waive any right of such hospital to a hearing before an administrative law judge with respect to the imposition of such penalty. ``(v) Provision of technical assistance.-- The Secretary shall, to the extent practicable, provide technical assistance relating to compliance with the provisions of this subsection to hospitals requesting such assistance. ``(vi) Hardship exemption.--Notwithstanding any limit on the waiver or reduction of a penalty under clause (iv), the Secretary may waive any penalty with respect to a hospital on a case-by-case basis if the Secretary determines that a circumstance exists interfering with such hospital's ability to comply with the provisions of this subsection (such as a natural disaster (as defined in section 602(a) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act), a public health emergency, or other similar or unexpected catastrophe or similar situation). ``(vii) Application of certain provisions.--The provisions of section 1128A of the Social Security Act (other than subsections (a) and (b) of such section) 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 (a) of such section. ``(viii) Nonduplication of penalties.-- ``(I) In general.--The Secretary may not subject a hospital to a civil monetary penalty under this subparagraph with respect to noncompliance with the provisions of this subsection for a period if the Secretary has imposed a civil monetary penalty on such hospital under section 1899D of the Social Security Act for failure to comply with the provisions of such section for such period. ``(II) Prioritization.--In the case of a hospital that the Secretary determines to be in violation of the provisions of this subsection and of section 1899D of the Social Security Act, the Secretary shall impose penalties as prescribed in this subsection in lieu of any penalties prescribed in such section 1899D. ``(C) Publication of hospital price transparency information.--Beginning on January 1, 2028, the Secretary shall make publicly available on the public website of the Centers for Medicare & Medicaid Services information with respect to compliance with the requirements of this subsection and enforcement activities undertaken by the Secretary under this subsection. Such information shall be updated in real time (if practicable) and include-- ``(i) the number of reviews of compliance with this subsection undertaken by the Secretary; ``(ii) the number of notifications described in subparagraph (A)(i) sent by the Secretary; ``(iii) the identity of each hospital that was sent such a notification and a description of the nature of such hospital's noncompliance with this subsection; ``(iv) the amount of any civil monetary penalty imposed on such hospital under subparagraph (B); ``(v) whether such hospital subsequently came into compliance with this subsection; ``(vi) any waivers or reductions of penalties made pursuant to a certification by the Secretary under subparagraph (B)(iv), including-- ``(I) the name of any hospital that received such a waiver or reduction; ``(II) the dollar amount of each such penalty so waived or reduced; and ``(III) the rationale for the granting of each such waiver or reduction, but only to the extent that such rationale does not make public commercially sensitive information; and ``(vii) any other information as determined by the Secretary. ``(5) Ensuring accessibility through implementation.--In implementing this subsection, the Secretary shall through rulemaking ensure that a hospital making public charges and prices pursuant to this section takes reasonable steps (as specified by the Secretary) to ensure the accessibility of such charges and information to individuals with limited English proficiency. Such steps may include the hospital's provision of interpretation services or the hospital's provision of translations of charges and information. ``(6) Definitions.--For purposes of this subsection: ``(A) Discounted cash price.--The term `discounted cash price' means the charge that applies to an individual who pays cash, or cash equivalent, for a hospital-furnished item or service. ``(B) Gross charge.--The term `gross charge' means the charge for an individual item or service that is reflected on a hospital's chargemaster, absent any discounts. ``(C) 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 service. ``(D) 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 service. ``(E) Third party payer.--The term `third party payer' means an entity that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.''. (2) Conforming amendments.--Section 2718 of the Public Health Service Act (42 U.S.C. 300gg-18) is amended-- (A) in subsection (b)(3), by inserting ``(other than the provisions of subsection (f))'' after ``this section''; and (B) in subsection (e), by adding at the end the following new sentence: ``The preceding provisions of this subsection shall not apply beginning on January 1, 2028.''. (3) Rule of construction.--Nothing in the amendments made by this subsection may be construed to impede, prohibit, or prevent the Secretary of Health and Human Services from implementing, executing, carrying out, or enforcing the requirements of section 1899D of the Social Security Act. SEC. 3. CLINICAL DIAGNOSTIC LABORATORY TEST PRICE TRANSPARENCY. Section 1846 of the Social Security Act (42 U.S.C. 1395w-2) is amended-- (1) in the header, by inserting ``and additional requirements'' after ``sanctions''; and (2) by adding at the end the following new subsection: ``(c) Price Transparency Requirement.-- ``(1) In general.--Beginning January 1, 2028, any applicable laboratory that receives payment under this title for furnishing any specified clinical diagnostic laboratory test under this title shall-- ``(A) make publicly available on an internet website the information described in paragraph (2) with respect to each such specified clinical diagnostic laboratory test that such laboratory so furnishes; ``(B) ensure that such information is updated not less frequently than annually; and ``(C) include on the website described in subparagraph (A) an attestation that all such information is complete and accurate. ``(2) Information described.--For purposes of paragraph (1), the information described in this paragraph is, with respect to an applicable laboratory and a specified clinical diagnostic laboratory test, the discounted cash price for such test (or, if no such price exists, the gross charge for such test). ``(3) Uniform method and format.--Not later than January 1, 2028, the Secretary shall establish a standard, uniform method and format for applicable laboratories to use in compiling and making public information pursuant to paragraph (1). Such method and format-- ``(A) may be similar to any template made available by the Centers for Medicare & Medicaid Services (as described in section 1899D(a)(2)(C)(ii)); ``(B) shall meet such standards as determined appropriate by the Secretary in order to ensure the accessibility and usability of such information; and ``(C) shall be updated as determined appropriate by the Secretary, in consultation with stakeholders. ``(4) Inclusion of ancillary services.--Any price or charge for a specified clinical diagnostic laboratory test furnished by an applicable laboratory made publicly available in accordance with paragraph (1) shall include the price or charge (as applicable) for any ancillary item or service (such as specimen collection services) that would normally be furnished by such laboratory as part of such test, as specified by the Secretary. ``(5) Enforcement.-- ``(A) In general.--In the case that the Secretary determines that an applicable laboratory is not in compliance with paragraph (1)-- ``(i) not later than 30 days after such determination, the Secretary shall notify such laboratory of such determination; and ``(ii) if such laboratory continues to fail to comply with such paragraph after the date that is 90 days after such notification is sent, the Secretary may impose a civil monetary penalty in an amount not to exceed $300 for each day (beginning with the day on which the Secretary first determined that such laboratory was failing to comply with such paragraph) during which such failure is ongoing. ``(B) Increase authority.--In applying this paragraph with respect to violations occurring in 2029 or a subsequent year, the Secretary may through notice and comment rulemaking increase the per day limitation on civil monetary penalties under subparagraph (A)(ii). ``(C) Application of certain provisions.--The provisions of section 1128A (other than subsections (a) and (b) of such section) 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 (a) of such section. ``(6) Provision of technical assistance.--The Secretary shall, to the extent practicable, provide technical assistance relating to compliance with the provisions of this subsection to applicable laboratories requesting such assistance. ``(7) Definitions.--In this subsection: ``(A) Applicable laboratory.--The term `applicable laboratory' has the meaning given such term in section 414.502, of title 42, Code of Federal Regulations (or a successor regulation), 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-- ``(i) a specified hospital pursuant to section 1899D; ``(ii) a hospital pursuant to section 2718(f) of the Public Health Service Act; or ``(iii) an ambulatory surgical center pursuant to section 1834(bb). ``(B) Discounted cash price.--The term `discounted cash price' means the charge that applies to an individual who pays cash, or cash equivalent, for an item or service. ``(C) Gross charge.--The term `gross charge' means the charge for an individual item or service that is reflected on an applicable laboratory's chargemaster (or similar list of prices), absent any discounts. ``(D) 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 (as described in section 1899D(a)(2)(A)(ii)(I)), other than an advanced diagnostic laboratory test (as defined in section 1834A(d)(5)). ``(E) Specified hospital.--The term `specified hospital' has the meaning given such term in section 1899D.''. SEC. 4. IMAGING PRICE TRANSPARENCY. Section 1899D of the Social Security Act, as added by section 2, is amended-- (1) by redesignating subsections (b) and (c) as subsections (c) and (d), respectively; (2) by inserting after subsection (a) the following new subsection: ``(b) Imaging Services Price Transparency.-- ``(1) In general.--Beginning January 1, 2028, each provider of services and supplier that receives payment under this title for furnishing a specified imaging service, other than such a provider or supplier with respect to which standard charges and prices for such services furnished by such provider or supplier are made available by a specified hospital pursuant to subsection (a), a hospital pursuant to section 2718(f) of the Public Health Service Act, or an ambulatory surgical center pursuant to section 1834(bb), shall-- ``(A) make publicly available (in accordance with paragraph (3)) on an internet website the information described in paragraph (2) with respect to each such service that such provider of services or supplier furnishes; ``(B) ensure that such information is updated not less frequently than annually; and ``(C) include on the website described in subparagraph (A) an attestation that all such information is complete and accurate. ``(2) Information described.--For purposes of paragraph (1), the information described in this paragraph is, with respect to a provider of services or supplier and a specified imaging service, the discounted cash price for such service (or, if no such price exists, the gross charge for such service). ``(3) Uniform method and format.--Not later than January 1, 2028, the Secretary shall establish a standard, uniform method and format for providers of services and suppliers to use in making public information described in paragraph (2). Any such method and format-- ``(A) may be similar to any template made available by the Centers for Medicare & Medicaid Services (as described in subsection (a)(2)(C)(ii)); ``(B) shall meet such standards as determined appropriate by the Secretary in order to ensure the accessibility and usability of such information; and ``(C) shall be updated as determined appropriate by the Secretary, in consultation with stakeholders. ``(4) Monitoring compliance.--The Secretary shall, through notice and comment rulemaking, establish a process to monitor compliance with this subsection. ``(5) Enforcement.-- ``(A) In general.--In the case that the Secretary determines that a provider of services or supplier is not in compliance with paragraph (1)-- ``(i) not later than 30 days after such determination, the Secretary shall notify such provider or supplier of such determination; ``(ii) upon request of the Secretary, such provider or supplier shall submit to the Secretary, not later than 45 days after the date of such request, a corrective action plan to comply with such paragraph; and ``(iii) if such provider or supplier continues to fail to comply with such paragraph after the date that is 90 days after such notification is sent (or, in the case of such a provider or supplier that has submitted a corrective action plan described in clause (ii) in response to a request so described, after the date that is 90 days after such submission), the Secretary may impose a civil monetary penalty in an amount not to exceed $300 for each day (beginning with the day on which the Secretary first determined that such provider or supplier was failing to comply with such paragraph) during which such failure to comply or failure to submit is ongoing. ``(B) Increase authority.--In applying this paragraph with respect to violations occurring in 2029 or a subsequent year, the Secretary may through notice and comment rulemaking increase the amount of the civil monetary penalty under subparagraph (A)(iii). ``(C) Application of certain provisions.--The provisions of section 1128A (other than subsections (a) and (b) of such section) 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 (a) of such section. ``(D) Authority to waive or reduce penalty.-- ``(i) In general.--Subject to clause (ii), the Secretary may waive or reduce any penalty otherwise applicable with respect to a provider of services or supplier under this subparagraph if the Secretary determines that imposition of such penalty would result in an immediate threat to access to care for individuals in the service area of such provider or supplier. ``(ii) Limitation.--The Secretary may not elect to waive or reduce a penalty under clause (i) with respect to a specific provider of services or supplier more than 3 times in a 10 year period. ``(E) Provision of technical assistance.--The Secretary shall, to the extent practicable, provide technical assistance relating to compliance with the provisions of this subsection to providers of services and suppliers requesting such assistance. ``(F) Clarification of nonapplicability of other enforcement provisions.--Notwithstanding any other provision of this title, this paragraph shall be the sole means of enforcing the provisions of this subsection.''; and (3) in subsection (d), as so redesignated by paragraph (1), by adding at the end the following new paragraph: ``(5) Specified imaging service.--the term `specified imaging service' means an imaging service that is included on the list of Centers for Medicare & Medicaid Services-specified shoppable services (as described in subsection (a)(2)(A)(ii)(I)).''. SEC. 5. AMBULATORY SURGICAL CENTER PRICE TRANSPARENCY. Section 1834 of the Social Security Act (42 U.S.C. 1395m) is amended by adding at the end the following new subsection: ``(bb) Ambulatory Surgical Center Price Transparency.-- ``(1) In general.--Beginning January 1, 2028, each ambulatory surgical center that receives payment under this title for furnishing items and services shall comply with the price transparency requirement described in paragraph (2). ``(2) Requirement described.-- ``(A) In general.--For purposes of paragraph (1), the price transparency requirement described in this subsection is, with respect to an ambulatory surgical center, that such surgical center in accordance with a method and format established by the Secretary under subparagraph (C), compile and make public (without subscription and free of charge), for each year-- ``(i) all of the ambulatory surgical center's standard charges (including the information described in subparagraph (B)) for each item and service furnished by such surgical center; ``(ii) information in a consumer-friendly format (as specified by the Secretary) on the ambulatory surgical center's prices (including the information described in subparagraph (B)) for as many of the Centers for Medicare & Medicaid Services-specified shoppable services (as specified by the Secretary) that are furnished by such surgical center, and as many additional ambulatory surgical center-selected shoppable services (or all such additional services, if such surgical center furnishes fewer than 300 shoppable services) as may be necessary for a combined total of at least 300 shoppable services; ``(iii) with respect to each Centers for Medicare & Medicaid Services-specified shoppable service that is not furnished by the ambulatory surgical center, an indication that such service is not so furnished; and ``(iv) an attestation that all standard charges described in clause (i), information described in clause (ii), and indications described in clause (iii) are complete and accurate. ``(B) Information described.--For purposes of subparagraph (A), the information described in this subparagraph is, with respect to standard charges and prices, as applicable, made public by an ambulatory surgical center, the following: ``(i) A plain language description (as specified by the Secretary) of each item or service, accompanied by, as applicable, the Healthcare Common Procedure Coding System code, the national drug code, or other identifier used or approved by the Centers for Medicare & Medicaid Services. ``(ii) The gross charge, as applicable, expressed as a dollar amount, for each such item or service. ``(iii) For each such item or service-- ``(I) the discounted cash price, as applicable, expressed as a dollar amount; or ``(II) in the case no discounted cash price is available for an item or service, the median cash price charged to self-pay individuals for such item or service for the previous three years, expressed as a dollar amount. ``(iv) Any other additional information the Secretary may require (in consultation with stakeholders) for the purpose of improving the accuracy of, or enabling consumers to easily understand and compare, standard charges and prices for an item or service, except information that is duplicative of any other reporting requirement under this subsection. ``(C) Uniform method and format.--Not later than January 1, 2028, the Secretary shall establish a standard, uniform method and format for ambulatory surgical centers to use in making public standard charges pursuant to subparagraph (A)(i) and a standard, uniform method and format for such centers to use in making public prices pursuant to subparagraph (A)(ii). Any such method and format-- ``(i) shall, in the case of such charges made public by an ambulatory surgical center, ensure that such charges are made available in a machine-readable format (or successor technology); ``(ii) may be similar to any template made available by the Centers for Medicare & Medicaid Services (as described in section 1899D(a)(2)(C)(ii)); ``(iii) shall meet such standards as determined appropriate by the Secretary in order to ensure the accessibility and usability of such charges and prices; and ``(iv) shall be updated as determined appropriate by the Secretary, in consultation with stakeholders. ``(3) Monitoring compliance.--The Secretary shall establish processes to monitor and assess ambulatory surgical centers' compliance with this subsection. Such processes shall include processes relating to the following: ``(A) The evaluation and analysis of complaints made by individuals or other entities relating to such centers' compliance with this subsection. ``(B) The use of audits to ensure such centers' compliance with this subsection. ``(C) The obtaining of additional information from such centers to determine such centers' compliance with this subsection (as determined appropriate by the Secretary). ``(4) Enforcement.-- ``(A) In general.--In the case of an ambulatory surgical center that fails to comply with the requirements of this subsection-- ``(i) the Secretary shall notify such ambulatory surgical center of such failure not later than 30 days after the date on which the Secretary determines such failure exists; and ``(ii) upon request of the Secretary, the ambulatory surgical center shall submit to the Secretary, not later than 45 days after the date of such request, a corrective action plan to comply with such requirements. ``(B) Civil monetary penalty.-- ``(i) In general.--In addition to any other enforcement actions or penalties that may apply under another provision of Federal law, an ambulatory surgical center that has received a notification under subparagraph (A)(i) and fails to comply with the requirements of this subsection by the date that is 90 days after such notification (or, in the case of an ambulatory surgical center that has submitted a corrective action plan described in subparagraph (A)(ii) in response to a request so described and has failed to comply with such requirements by the date that is 90 days after such submission) shall be subject to a civil monetary penalty of an amount specified by the Secretary for each day (beginning with the day on which the Secretary first determined that such center was not complying with such requirements) during which such failure is ongoing (not to exceed $300 per day). ``(ii) Increase authority.--In applying this subparagraph with respect to violations occurring in 2029 or a subsequent year, the Secretary may through notice and comment rulemaking increase the limitation on the per day amount of any penalty applicable to an ambulatory surgical center under clause (i). ``(iii) Application of certain provisions.--The provisions of section 1128A (other than subsections (a) and (b) of such section) 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 (a) of such section. ``(iv) Authority to waive or reduce penalty.-- ``(I) Centers located in rural or underserved areas.-- ``(aa) In general.--Subject to item (bb), the Secretary may waive any penalty, or reduce any penalty by not more than 75 percent, otherwise applicable under this subparagraph with respect to an ambulatory surgical center located in a rural or underserved area if the Secretary certifies that imposition of such penalty would result in an immediate threat to access to care for individuals in the service area of such center. ``(bb) Limitation on application.--The Secretary may not elect to waive a penalty under item (aa) with respect to an ambulatory surgical center more than once in a 6-year period and may not elect to reduce such a penalty with respect to such a center more than once in such a period. Nothing in the preceding sentence shall be construed as prohibiting the Secretary from both waiving and reducing a penalty with respect to an ambulatory surgical center during a 6-year period. ``(II) Reduction if hearing waived.--The Secretary may reduce any penalty otherwise applicable under this subparagraph (as reduced, if applicable, under subclause (I)) by not more than 35 percent if the ambulatory surgical center that is the subject of such penalty agrees to waive any right of such center to a hearing before an administrative law judge with respect to the imposition of such penalty. ``(5) Provision of technical assistance.--The Secretary shall, to the extent practicable, provide technical assistance relating to compliance with the provisions of this subsection to ambulatory surgical centers requesting such assistance. ``(6) Definitions.--For purposes of this subsection: ``(A) Discounted cash price.--The term `discounted cash price' means the charge that applies to an individual who pays cash, or cash equivalent, for an item or service furnished by an ambulatory surgical center. ``(B) Gross charge.--The term `gross charge' means the charge for an individual item or service that is reflected on an ambulatory surgical center's chargemaster, absent any discounts. ``(C) 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 service.''. SEC. 6. HEALTH COVERAGE PRICE TRANSPARENCY. (a) Price Transparency Requirements.-- (1) IRC.-- (A) In general.--Section 9819 of the Internal Revenue Code of 1986 is amended-- (i) in the header, by striking ``maintenance of price comparison tool'' and inserting ``transparency in coverage''; (ii) by striking ``A group health plan'' and inserting the following: ``(a) Maintenance of Price Comparison Tool for Plan Years Before 2028.-- ``(1) In general.--A group health plan''; (iii) in subsection (a), as inserted by clause (ii), by adding at the end the following new paragraph: ``(2) Sunset.--Paragraph (1) shall not apply with respect to plan years beginning on or after January 1, 2028.''; and (iv) by adding at the end the following new subsections: ``(b) Cost-sharing Transparency.-- ``(1) In general.--For plan years beginning on or after January 1, 2028, a group health plan shall provide a participant or beneficiary, in a timely manner upon request of the participant or beneficiary, information on the amount of cost-sharing (including deductibles, copayments, and coinsurance) under the participant or beneficiary's plan that the participant or beneficiary would be responsible for paying with respect to the furnishing of a specific item or service by a provider. At a minimum, such information shall include the information specified in paragraph (2) and shall be made available to such participant or beneficiary through a self- service tool that meets the requirements of paragraph (3) or, at the option of such participant or beneficiary, through a paper disclosure or phone or other electronic disclosure (as selected by such participant or beneficiary and provided at no cost to such participant or beneficiary) that meets such requirements as the Secretary may specify. ``(2) Specified information.--For purposes of paragraph (1), the information specified in this paragraph is, with respect to an item or service for which benefits are available under a group health plan furnished by a health care provider to a participant or beneficiary of such plan, the following: ``(A) If such provider is a participating provider with respect to such item or service, the in-network rate for such item or service. ``(B) If such provider is not a participating provider with respect to such item or service, the maximum allowed amount or other dollar amount that such plan will recognize as payment for such item or service, along with a notice that such participant or beneficiary may be liable for additional charges. ``(C) The estimated amount of cost sharing (including deductibles, copayments, and coinsurance) that the participant or beneficiary will incur for such item or service (which, in the case such item or service is to be furnished by a provider described in subparagraph (B), shall be calculated using the maximum allowed amount or other dollar amount described in such subparagraph). ``(D) The amount the participant or beneficiary has already accumulated with respect to any deductible or out of pocket maximum under the plan (broken down, in the case separate deductibles or maximums apply to a participant and such participant's beneficiaries enrolled in the plan, by such separate deductibles or maximums, in addition to any cumulative deductible or maximum). ``(E) In the case such plan imposes any frequency or volume limitations with respect to such item or service (excluding medical necessity determinations), the amount that such participant or beneficiary has accrued towards such limitation with respect to such item or service. ``(F) Any prior authorization, concurrent review, step therapy, fail first, or similar requirements applicable to coverage of such item or service under such plan. ``(G) Any financial incentives (such as any credit, payment, or other benefit provided by such plan) available to the participant or beneficiary with respect to such item or service furnished by such provider known at the time such request is made. ``(H) In the case such item or service is an applicable spread price drug dispensed by a pharmacy-- ``(i) a specification that such item or service is such an applicable spread price drug; ``(ii) the amount of the difference (if any) between the specified payment amount for such drug so dispensed by such pharmacy and the specified reimbursement amount for such drug so dispensed by such pharmacy; ``(iii) a plain language statement specified by the Secretary that explains the concept of spread pricing and how such item's status as such an applicable spread price drug may impact the amount such plan pays for such drug and cost sharing amounts for such drug described in subparagraph (C); and ``(iv) a plain language statement specified by the Secretary informing the participant or beneficiary of the participant's or beneficiary's ability to obtain a summary document relating to drug pricing information described in section 9826(b)(2)(B)(ii). ``(3) Self-service tool.--For purposes of paragraph (1), a self-service tool established by a group health plan meets the requirements of this paragraph if such tool-- ``(A) is based on an Internet website (or successor technology specified by the Secretary); ``(B) provides for real-time responses to requests described in paragraph (1); ``(C) is updated in a manner such that information provided through such tool is timely and accurate at the time such request is made; ``(D) allows such a request to be made with respect to an item or service furnished by-- ``(i) a specific provider that is a participating provider with respect to such item or service; ``(ii) all providers that are participating providers with respect to such item or service; or ``(iii) a provider located in a relevant geographic region that is not a participating provider with respect to such item or service; ``(E) provides that such a request may be made with respect to an item or service through use of the billing code for such item or service or through use of a descriptive term for such item or service; and ``(F) meets any other requirement determined appropriate by the Secretary, including requirements to ensure the accessibility and usability of information provided through such tool. The Secretary may require such tool, as a condition of complying with subparagraph (E), to link multiple billing codes to a single descriptive term if the Secretary determines that the billing codes to be so linked correspond to similar items and services. ``(c) Rate and Payment Information.-- ``(1) In general.--For plan years beginning on or after January 1, 2028, each group health plan (other than a grandfathered health plan (as defined in section 1251(e) of the Patient Protection and Affordable Care Act)) shall make available to the public the rate and payment information described in paragraph (2) in accordance with paragraph (3). ``(2) Rate and payment information described.--For purposes of paragraph (1), the rate and payment information described in this paragraph is, with respect to a group health plan, the following: ``(A) With respect to each item or service (other than a drug) for which benefits are available under such plan-- ``(i) the in-network rate (expressed as a dollar amount) in effect as of the date on which such information is made public with each provider that is a participating provider with respect to such item or service; ``(ii) with respect to each such provider, an indication of whether, during the 1-year period beginning 18 months before the date such information is made public, such provider submitted a claim for such item or service to such plan; and ``(iii) in the case that such plan provides benefits for such item or service only when furnished by a specific type of provider, a specification of each type of provider that may furnish such item or service under such plan; ``(B) With respect to each drug (identified by national drug code) for which benefits are available under such plan-- ``(i) the in-network rate (expressed as a dollar amount) 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 drug; ``(ii) the average amount paid by such plan (accounting for, in a manner determined appropriate by the Secretary, rebates, discounts, price concessions, and any other remuneration specified by the Secretary) for such drug dispensed or administered during the 90-day period beginning 180 days before such date of publication to each provider that was a participating provider with respect to such drug, broken down by each such provider, unless fewer than 20 claims for such drug were submitted to such plan during such period; and ``(iii) in the case such drug is an applicable spread price drug dispensed by a pharmacy-- ``(I) a specification that such drug is such an applicable spread price drug; and ``(II) for each pharmacy that has a contractual relationship for dispensing such drug under such plan, a specification of the difference (if any) between the specified payment amount for such drug so dispensed by such pharmacy and the specified reimbursement amount for such drug so dispensed by such pharmacy. ``(C) With respect to each item or service for which benefits are available under such plan, the amount billed, and the amount allowed by the plan, for each such item or service furnished during the 6-month period beginning 9 months before the date such information is made public by a provider that was not a participating provider with respect to such item or service, broken down by each such provider, other than such an amount with respect to an item or service furnished by a provider that, during such period, submitted fewer than 11 claims for such item or service to such plan. ``(3) Manner of publication.-- ``(A) In general.--Rate and payment information required to be made available under this subsection shall be so made available in dollar amounts through separate machine-readable files (and any successor technology, as applicable, such as application programming interface technology, determined appropriate by the Secretary) corresponding to the information described in each of subparagraphs (A) through (C) of paragraph (2) that meet such requirements as specified by the Secretary (which may be so specified through subregulatory guidance). Such requirements shall ensure that such files are limited to an appropriate size, do not include disclosure of unnecessary duplicative information contained in other files made available under this subsection, are made available in a widely available format through a publicly available website that allows for information contained in such files to be compared across group health plans and group or individual health insurance coverage, and are accessible to individuals at no cost and without the need to establish a user account or provide other credentials. ``(B) Timing.--Rate and payment information-- ``(i) described in subparagraph (A) or (B) of paragraph (2) shall be made public on a quarterly basis; and ``(ii) described in subparagraph (C) of paragraph (2) shall be made public on a monthly basis. ``(4) User instructions.--Each group health plan shall make available to the public instructions written in plain language explaining how individuals may search for information described in paragraph (2) in files submitted in accordance with paragraph (3). The Secretary shall develop and publish through subregulatory guidance a template that such a plan may use in developing instructions for purposes of the preceding sentence. ``(5) Summary.--For each plan year beginning on or after January 1, 2028, each group health plan shall make public a data file, in a manner that ensures that such file may be easily downloaded and read by standard spreadsheet software and that meets such requirements as established by the Secretary, containing a summary of all rate and payment information made public by such plan with respect to such plan during such plan year. Such file shall include the following: ``(A) The mean, median, and interquartile range of the in-network rate, and the amount allowed for an item or service when not furnished by a participating provider, in effect as of the first day of such plan year for each item or service (identified by payer identifier approved or used by the Centers for Medicare & Medicaid Services) for which benefits are available under the plan, broken down by the type of provider furnishing the item or service and by the geographic area in which such item or service is furnished. ``(B) Trends in payment rates for such items and services over such plan year, including an identification of instances in which such rates have increased, decreased, or remained the same. ``(C) The name of such plan, a description of the type of network of participating providers used by such plan, and a description of whether such plan is self- insured or fully-insured. ``(D) For each item or service which is paid as part of a bundled or capitated rate-- ``(i) a description of the formulae, pricing methodologies, or other information used to calculate the payment rate for such rate; and ``(ii) a list of the items and services included in such rate. ``(E) The percentage of items and services that are paid for on a fee-for-service basis and the percentage of items and services that are paid for as part of a bundled rate, capitated payment rate, or other alternative payment model. ``(d) Attestation.--Each group health plan shall annually submit to the Secretary an attestation of such plan's compliance with the provisions of this section. Such attestation shall include a link to the website (or other successor technology) where rate and payment information required to be made public under subsection (c) may be accessed. ``(e) Accessibility.--A group health plan shall take reasonable steps (as specified by the Secretary) to ensure that information provided in response to a request described in subsection (b), and rate and payment information made public under subsection (c), is provided in plain, easily understandable language and that interpretation, translations, and assistive services are provided to those with limited English proficiency and those with disabilities. ``(f) PBM Disclosure of Applicable Spread Price Drugs.--An entity providing pharmacy benefit management services on behalf of a group health plan shall disclose to such plan, at such time and in such manner as specified by the Secretary to ensure that information provided under subsection (b) and rate and payment information made public under subsection (c) is timely and accurate-- ``(1) a list of drugs (identified by national drug codes) for which benefits are available under such plan that are applicable spread price drugs; and ``(2) with respect to each drug included on such list and each pharmacy with a contractual relationship for furnishing such drug under such plan, a specification of the difference (if any) between the specified payment amount for such drug so dispensed by such pharmacy and the specified reimbursement amount for such drug so dispensed by such pharmacy. ``(g) Definitions.--In this section: ``(1) Applicable spread price drug.--The term `applicable spread price drug' means, with respect to a group health plan, a drug for which benefits are available under such plan and with respect to which, at the time a disclosure described in subsection (f) is required to be made by an entity providing pharmacy benefit management services on behalf of such plan-- ``(A) a contract is in effect between such entity and a pharmacy for the dispensing of such drug under such plan; and ``(B) the specified payment amount for such drug so dispensed is less than the specified reimbursement amount for such drug so dispensed. ``(2) In-network rate.--The term `in-network rate' means, with respect to a group health plan and an item or service furnished by a provider that is a participating provider with respect to such plan and item or service, the contracted rate (reflected as a dollar amount) in effect between such plan and such provider for such item or service, regardless of whether such rate is calculated based on a set amount, a fee schedule, or an amount derived from another amount, or a formula, or other method. ``(3) Participating provider.--The term `participating provider' means, with respect to an item or service and a group health plan, a physician or other health care provider (as defined in paragraph (4)) who is acting within the scope of practice of that provider's license or certification under applicable State law and who has a contractual relationship with the plan for furnishing such item or service under the plan. ``(4) Provider.--The term `provider' includes a health care facility and a pharmacy. ``(5) Specified payment amount.--The term `specified payment amount' means, with respect to a drug to be dispensed by a pharmacy to a participant or beneficiary of a group health plan where such pharmacy has in effect a contract with an entity providing pharmacy benefit management services on behalf of such plan for the dispensing of such drug under such plan, the amount that such entity has agreed to pay such pharmacy for the ingredient costs and any applicable dispensing fee for such drug (or the amount that such entity has agreed to pay such pharmacy for such drug under any other compensation structure specified by the Secretary) under such contract, taking into account any cost sharing requirement applicable to such drug and participant or beneficiary. ``(6) Specified reimbursement amount.--The term `specified reimbursement amount' means, with respect to a drug to be dispensed by a pharmacy to a participant or beneficiary of a group health plan where such pharmacy has in effect a contract with an entity providing pharmacy benefit management services on behalf of such plan for the dispensing of such drug under such plan, that amount that such plan has agreed to pay to such entity for the ingredient costs and any applicable dispensing fee for such drug (or the amount that such plan has agreed to pay such entity for such drug under any other compensation structure specified by the Secretary), taking into account any cost sharing requirement applicable to such drug and participant or beneficiary.''. (B) Clerical amendment.--The item relating to section 9819 of the table of sections for subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended to read as follows: ``Sec. 9819. Transparency in coverage.''. (2) PHSA.--Section 2799A-4 of the Public Health Service Act (42 U.S.C. 300gg-114) is amended-- (A) in the header, by striking ``maintenance of price comparison tool'' and inserting ``transparency in coverage''; (B) by striking ``A group health plan'' and inserting the following: ``(a) Maintenance of Price Comparison Tool for Plan Years Before 2028.-- ``(1) In general.--A group health plan''; (C) in subsection (a), as inserted by subparagraph (B), by adding at the end the following new paragraph: ``(2) Sunset.--Paragraph (1) shall not apply with respect to plan years beginning on or after January 1, 2028.''; and (D) by adding at the end the following new subsections: ``(b) Cost-sharing Transparency.-- ``(1) In general.--For plan years beginning on or after January 1, 2028, a group health plan and a health insurance issuer offering group or individual health insurance coverage shall provide a participant, beneficiary, or enrollee, in a timely manner upon request of the participant, beneficiary, or enrollee, information on the amount of cost-sharing (including deductibles, copayments, and coinsurance) under the participant, beneficiary, or enrollee's plan or coverage that the participant, beneficiary, or enrollee would be responsible for paying with respect to the furnishing of a specific item or service by a provider. At a minimum, such information shall include the information specified in paragraph (2) and shall be made available to such participant, beneficiary, or enrollee through a self-service tool that meets the requirements of paragraph (3) or, at the option of such participant, beneficiary, or enrollee, through a paper disclosure or phone or other electronic disclosure (as selected by such individual and provided at no cost to such individual) that meets such requirements as the Secretary may specify. ``(2) Specified information.--For purposes of paragraph (1), the information specified in this paragraph is, with respect to an item or service for which benefits are available under a group health plan or group or individual health insurance coverage furnished by a health care provider to an individual enrolled under such plan or coverage, the following: ``(A) If such provider is a participating provider with respect to such item or service, the in-network rate for such item or service. ``(B) If such provider is not a participating provider with respect to such item or service, the maximum allowed amount or other dollar amount that such plan or coverage will recognize as payment for such item or service, along with a notice that such individual may be liable for additional charges. ``(C) The estimated amount of cost sharing (including deductibles, copayments, and coinsurance) that the individual will incur for such item or service (which, in the case such item or service is to be furnished by a provider described in subparagraph (B), shall be calculated using the maximum allowed amount or other dollar amount described in such subparagraph). ``(D) The amount the individual has already accumulated with respect to any deductible or out of pocket maximum under the plan or coverage (broken down, in the case separate deductibles or maximums apply to individuals enrolled in the plan or coverage, by such separate deductibles or maximums, in addition to any cumulative deductible or maximum). ``(E) In the case such plan imposes any frequency or volume limitations with respect to such item or service (excluding medical necessity determinations), the amount that such individual has accrued towards such limitation with respect to such item or service. ``(F) Any prior authorization, concurrent review, step therapy, fail first, or similar requirements applicable to coverage of such item or service under such plan or coverage. ``(G) Any financial incentives (such as any credit, payment, or other benefit provided by such plan or issuer) available to the individual with respect to such item or service furnished by such provider known at the time such request is made. ``(H) In the case such item or service is an applicable spread price drug dispensed by a pharmacy-- ``(i) a specification that such item or service is such an applicable spread price drug; ``(ii) the amount of the difference (if any) between the specified payment amount for such drug so dispensed by such pharmacy and the specified reimbursement amount for such drug so dispensed by such pharmacy; ``(iii) a plain language statement specified by the Secretary that explains the concept of spread pricing and how such item's status as such an applicable spread price drug may impact the amount such plan or coverage pays for such drug and cost sharing amounts for such drug described in subparagraph (C); and ``(iv) except in the case of individual health insurance coverage, a plain language statement specified by the Secretary informing the participant or beneficiary of the participant's or beneficiary's ability to obtain a summary document relating to drug pricing information described in section 2799A- 11(b)(2)(B)(ii). ``(3) Self-service tool.--For purposes of paragraph (1), a self-service tool established by a group health plan or health insurance issuer offering group or individual health insurance coverage meets the requirements of this paragraph if such tool-- ``(A) is based on an internet website (or successor technology specified by the Secretary); ``(B) provides for real-time responses to requests described in paragraph (1); ``(C) is updated in a manner such that information provided through such tool is timely and accurate at the time such request is made; ``(D) allows such a request to be made with respect to an item or service furnished by-- ``(i) a specific provider that is a participating provider with respect to such item or service; ``(ii) all providers that are participating providers with respect to such item or service; or ``(iii) a provider located in a relevant geographic region that is not a participating provider with respect to such item or service; ``(E) provides that such a request may be made with respect to an item or service through use of the billing code for such item or service or through use of a descriptive term for such item or service; and ``(F) meets any other requirement determined appropriate by the Secretary, including requirements to ensure the accessibility and usability of information provided through such tool. The Secretary may require such tool, as a condition of complying with subparagraph (E), to link multiple billing codes to a single descriptive term if the Secretary determines that the billing codes to be so linked correspond to similar items and services. ``(c) Rate and Payment Information.-- ``(1) In general.--For plan years beginning on or after January 1, 2028, each group health plan and health insurance issuer offering group or individual health insurance coverage (other than a grandfathered health plan (as defined in section 1251(e) of the Patient Protection and Affordable Care Act)) shall make available to the public the rate and payment information described in paragraph (2) in accordance with paragraph (3). ``(2) Rate and payment information described.--For purposes of paragraph (1), the rate and payment information described in this paragraph is, with respect to a group health plan or group or individual health insurance coverage, the following: ``(A) With respect to each item or service (other than a drug) for which benefits are available under such plan or coverage,-- ``(i) the in-network rate (expressed as a dollar amount) in effect as of the date on which such information is made public with each provider that is a participating provider with respect to such item or service; ``(ii) with respect to each such provider, an indication of whether, during the 1-year period beginning 18 months before the date such information is made public, such provider submitted a claim for such item or service to such plan or coverage; and ``(iii) in the case that such plan or coverage provides benefits for such item or service only when furnished by a specific type of provider, a specification of each type of provider that may furnish such item or service under such plan or coverage; ``(B) With respect to each drug (identified by national drug code) for which benefits are available under such plan or coverage-- ``(i) the in-network rate (expressed as a dollar amount) 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 drug; ``(ii) the average amount paid by such plan or coverage (accounting for, in a manner determined appropriate by the Secretary, rebates, discounts, price concessions, and any other remuneration specified by the Secretary) for such drug dispensed or administered during the 90-day period beginning 180 days before such date of publication to each provider that was a participating provider with respect to such drug, broken down by each such provider, unless fewer than 20 claims for such drug were submitted to such plan or coverage during such period; and ``(iii) in the case such drug is an applicable spread price drug dispensed by a pharmacy-- ``(I) a specification that such drug is such an applicable spread price drug; and ``(II) for each pharmacy that has a contractual relationship for dispensing such drug under such plan or coverage, a specification of the difference (if any) between the specified payment amount for such drug so dispensed by such pharmacy and the specified reimbursement amount for such drug so dispensed by such pharmacy. ``(C) With respect to each item or service for which benefits are available under such plan or coverage, the amount billed, and the amount allowed by the plan, for each such item or service furnished during the 6-month period beginning 9 months before the date such information is made public by a provider that was not a participating provider with respect to such item or service, broken down by each such provider, other than such an amount with respect to an item or service furnished by a provider that, during such period, submitted fewer than 11 claims for such item or service to such plan or coverage. ``(3) Manner of publication.-- ``(A) In general.--Rate and payment information required to be made available under this subsection shall be so made available in dollar amounts through separate machine-readable files (and any successor technology, as applicable, such as application programming interface technology, determined appropriate by the Secretary) corresponding to the information described in each of subparagraphs (A) through (C) of paragraph (2) that meet such requirements as specified by the Secretary (which may be so specified through subregulatory guidance). Such requirements shall ensure that such files are limited to an appropriate size, do not include disclosure of unnecessary duplicative information contained in other files made available under this subsection, are made available in a widely-available format through a publicly-available website that allows for information contained in such files to be compared across group health plans and group or individual health insurance coverage, and are accessible to individuals at no cost and without the need to establish a user account or provide other credentials. ``(B) Timing.--Rate and payment information-- ``(i) described in subparagraph (A) or (B) of paragraph (2) shall be made public on a quarterly basis; and ``(ii) described in subparagraph (C) of paragraph (2) shall be made public on a monthly basis. ``(4) User instructions.--Each group health plan and health insurance issuer offering group or individual health insurance coverage shall make available to the public instructions written in plain language explaining how individuals may search for information described in paragraph (2) in files submitted in accordance with paragraph (3). The Secretary shall develop and publish through subregulatory guidance a template that such a plan may use in developing instructions for purposes of the preceding sentence. ``(5) Summary.--For each plan year beginning on or after January 1, 2028, each group health plan and health insurance issuer offering group or individual health insurance coverage shall make public a data file, in a manner that ensures that such file may be easily downloaded and read by standard spreadsheet software and that meets such requirements as established by the Secretary, containing a summary of all rate and payment information made public by such plan or issuer with respect to such plan or coverage during such plan year. Such file shall include the following: ``(A) The mean, median, and interquartile range of the in-network rate, and the amount allowed for an item or service when not furnished by a participating provider, in effect as of the first day of such plan year for each item or service (identified by payer identifier approved or used by the Centers for Medicare & Medicaid Services) for which benefits are available under the plan or coverage, broken down by the type of provider furnishing the item or service and by the geographic area in which such item or service is furnished. ``(B) Trends in payment rates for such items and services over such plan year, including an identification of instances in which such rates have increased, decreased, or remained the same. ``(C) The name of such plan, a description of the type of network of participating providers used by such plan or coverage, and, in the case of a group health plan, a description of whether such plan is self- insured or fully-insured. ``(D) For each item or service which is paid as part of a bundled or capitated rate-- ``(i) a description of the formulae, pricing methodologies, or other information used to calculate the payment rate for such rate; and ``(ii) a list of the items and services included in such rate. ``(E) The percentage of items and services that are paid for on a fee-for-service basis and the percentage of items and services that are paid for as part of a bundled rate, capitated payment rate, or other alternative payment model. ``(d) Attestation.--Each group health plan and health insurance issuer offering group or individual health insurance coverage shall annually submit to the Secretary an attestation of such plan's or coverage's compliance with the provisions of this section. Such attestation shall include a link to the website (or other successor technology) where rate and payment information required to be made public under subsection (c) may be accessed. ``(e) Accessibility.--A group health plan and a health insurance issuer offering group or individual health insurance coverage shall take reasonable steps (as specified by the Secretary) to ensure that information provided in response to a request described in subsection (b), and rate and payment information made public under subsection (c), is provided in plain, easily understandable language and that interpretation, translations, and assistive services are provided to those with limited English proficiency and those with disabilities. ``(f) PBM Disclosure of Applicable Spread Price Drugs.--An entity providing pharmacy benefit management services on behalf of a group health plan or group or individual health insurance coverage shall disclose to such plan or coverage, at such time and in such manner as specified by the Secretary to ensure that information provided under subsection (b) and rate and payment information made public under subsection (c) is timely and accurate-- ``(1) a list of drugs (identified by national drug codes) for which benefits are available under such plan that are applicable spread price drugs; and ``(2) with respect to each drug included on such list and each pharmacy with a contractual relationship for furnishing such drug under such plan or coverage, a specification of the difference (if any) between the specified payment amount for such drug so dispensed by such pharmacy and the specified reimbursement amount for such drug so dispensed by such pharmacy. ``(g) Definitions.--In this section: ``(1) Applicable spread price drug.--The term `applicable spread price drug' means, with respect to a group health plan or group or individual health insurance coverage, a drug for which benefits are available under such plan or coverage and with respect to which, at the time a disclosure described in subsection (f) is required to be made by an entity providing pharmacy benefit management services on behalf of such plan or coverage-- ``(A) a contract is in effect between such entity and a pharmacy for the dispensing of such drug under such plan or coverage; and ``(B) the specified payment amount for such drug so dispensed is less than the specified reimbursement amount for such drug so dispensed. ``(2) In-network rate.--The term `in-network rate' means, with respect to a group health plan or group or individual health insurance coverage and an item or service furnished by a provider that is a participating provider with respect to such plan or coverage and item or service, the contracted rate (reflected as a dollar amount) in effect between such plan or coverage and such provider for such item or service, regardless of whether such rate is calculated based on a set amount, a fee schedule, or an amount derived from another amount, or a formula, or other method. ``(3) Participating provider.--The term `participating provider' means, with respect to an item or service and a group health plan or health insurance issuer offering group or individual health insurance coverage, a physician or other health care provider (as defined in paragraph (4)) who is acting within the scope of practice of that provider's license or certification under applicable State law and who has a contractual relationship with the plan or issuer, respectively, for furnishing such item or service under the plan or coverage, respectively. ``(4) Provider.--The term `provider' includes a health care facility and a pharmacy. ``(5) Specified payment amount.--The term `specified payment amount' means, with respect to a drug to be dispensed by a pharmacy to a participant, beneficiary, or enrollee of a group health plan or group or individual health insurance coverage where such pharmacy has in effect a contract with an entity providing pharmacy benefit management services on behalf of such plan or coverage for the dispensing of such drug under such plan or coverage, the amount that such entity has agreed to pay such pharmacy for the ingredient costs and any applicable dispensing fee for such drug (or the amount that such entity has agreed to pay such pharmacy for such drug under any other compensation structure specified by the Secretary) under such contract, taking into account any cost sharing requirement applicable to such drug and participant, beneficiary, or enrollee. ``(6) Specified reimbursement amount.--The term `specified reimbursement amount' means, with respect to a drug to be dispensed by a pharmacy to a participant, beneficiary, or enrollee of a group health plan or group or individual health insurance coverage where such pharmacy has in effect a contract with an entity providing pharmacy benefit management services on behalf of such plan or coverage for the dispensing of such drug under such plan or coverage, that amount that such plan or coverage has agreed to pay to such entity for the ingredient costs and any applicable dispensing fee for such drug (or the amount that such plan or coverage has agreed to pay such entity for such drug under any other compensation structure specified by the Secretary), taking into account any cost sharing requirement applicable to such drug and participant, beneficiary, or enrollee.''. (3) ERISA.-- (A) In general.--Section 719 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185h) is amended-- (i) in the header, by striking ``maintenance of price comparison tool'' and inserting ``transparency in coverage''; (ii) by striking ``A group health plan'' and inserting the following: ``(a) Maintenance of Price Comparison Tool for Plan Years Before 2028.-- ``(1) In general.--A group health plan''; (iii) in subsection (a), as inserted by clause (ii), by adding at the end the following new paragraph: ``(2) Sunset.--Paragraph (1) shall not apply with respect to plan years beginning on or after January 1, 2028.''; and (iv) by adding at the end the following new subsections: ``(b) Cost-Sharing Transparency.-- ``(1) In general.--For plan years beginning on or after January 1, 2028, a group health plan and a health insurance issuer offering group health insurance coverage shall provide a participant or beneficiary, in a timely manner upon request of the participant or beneficiary, information on the amount of cost-sharing (including deductibles, copayments, and coinsurance) under the participant or beneficiary's plan or coverage that the participant or beneficiary would be responsible for paying with respect to the furnishing of a specific item or service by a provider. At a minimum, such information shall include the information specified in paragraph (2) and shall be made available to such participant or beneficiary through a self-service tool that meets the requirements of paragraph (3) or, at the option of such participant or beneficiary, through a paper disclosure or phone or other electronic disclosure (as selected by such participant or beneficiary and provided at no cost to such participant or beneficiary) that meets such requirements as the Secretary may specify. ``(2) Specified information.--For purposes of paragraph (1), the information specified in this paragraph is, with respect to an item or service for which benefits are available under a group health plan or group health insurance coverage furnished by a health care provider to a participant or beneficiary of such plan or coverage, the following: ``(A) If such provider is a participating provider with respect to such item or service, the in-network rate for such item or service. ``(B) If such provider is not a participating provider with respect to such item or service, the maximum allowed amount or other dollar amount that such plan or coverage will recognize as payment for such item or service, along with a notice that such participant or beneficiary may be liable for additional charges. ``(C) The estimated amount of cost-sharing (including deductibles, copayments, and coinsurance) that the participant or beneficiary will incur for such item or service (which, in the case such item or service is to be furnished by a provider described in subparagraph (B), shall be calculated using the maximum allowed amount or other dollar amount described in such subparagraph). ``(D) The amount the participant or beneficiary has already accumulated with respect to any deductible or out of pocket maximum under the plan or coverage (broken down, in the case separate deductibles or maximums apply to a participant and such participant's beneficiaries enrolled in the plan or coverage, by such separate deductibles or maximums, in addition to any cumulative deductible or maximum). ``(E) In the case such plan imposes any frequency or volume limitations with respect to such item or service (excluding medical necessity determinations), the amount that such participant or beneficiary has accrued towards such limitation with respect to such item or service. ``(F) Any prior authorization, concurrent review, step therapy, fail first, or similar requirements applicable to coverage of such item or service under such plan or coverage. ``(G) Any financial incentives (such as any credit, payment, or other benefit provided by such plan or issuer) available to the participant or beneficiary with respect to such item or service furnished by such provider known at the time such request is made. ``(H) In the case such item or service is an applicable spread price drug dispensed by a pharmacy-- ``(i) a specification that such item or service is such an applicable spread price drug; ``(ii) the amount of the difference (if any) between the specified payment amount for such drug so dispensed by such pharmacy and the specified reimbursement amount for such drug so dispensed by such pharmacy; ``(iii) a plain language statement specified by the Secretary that explains the concept of spread pricing and how such item's status as such an applicable spread price drug may impact the amount such plan or coverage pays for such drug and cost sharing amounts for such drug described in subparagraph (C); and ``(iv) a plain language statement specified by the Secretary informing the participant or beneficiary of the participant's or beneficiary's ability to obtain a summary document relating to drug pricing information described in section 726(b)(2)(B)(ii). ``(3) Self-service tool.--For purposes of paragraph (1), a self-service tool established by a group health plan or health insurance issuer offering group health insurance coverage meets the requirements of this paragraph if such tool-- ``(A) is based on an internet website (or successor technology specified by the Secretary); ``(B) provides for real-time responses to requests described in paragraph (1); ``(C) is updated in a manner such that information provided through such tool is timely and accurate at the time such request is made; ``(D) allows such a request to be made with respect to an item or service furnished by-- ``(i) a specific provider that is a participating provider with respect to such item or service; ``(ii) all providers that are participating providers with respect to such item or service; or ``(iii) a provider located in a relevant geographic region that is not a participating provider with respect to such item or service; ``(E) provides that such a request may be made with respect to an item or service through use of the billing code for such item or service or through use of a descriptive term for such item or service; and ``(F) meets any other requirement determined appropriate by the Secretary, including requirements to ensure the accessibility and usability of information provided through such tool. The Secretary may require such tool, as a condition of complying with subparagraph (E), to link multiple billing codes to a single descriptive term if the Secretary determines that the billing codes to be so linked correspond to similar items and services. ``(c) Rate and Payment Information.-- ``(1) In general.--For plan years beginning on or after January 1, 2028, each group health plan and health insurance issuer offering group health insurance coverage (other than a grandfathered health plan (as defined in section 1251(e) of the Patient Protection and Affordable Care Act)) shall make available to the public the rate and payment information described in paragraph (2) in accordance with paragraph (3). ``(2) Rate and payment information described.--For purposes of paragraph (1), the rate and payment information described in this paragraph is, with respect to a group health plan or group health insurance coverage, the following: ``(A) With respect to each item or service (other than a drug) for which benefits are available under such plan or coverage-- ``(i) the in-network rate (expressed as a dollar amount) in effect as of the date on which such information is made public with each provider that is a participating provider with respect to such item or service; ``(ii) with respect to each such provider, an indication of whether, during the 1-year period beginning 18 months before the date such information is made public, such provider submitted a claim for such item or service to such plan or coverage; and ``(iii) in the case that such plan or coverage provides benefits for such item or service only when furnished by a specific type of provider, a specification of each type of provider that may furnish such item or service under such plan or coverage; ``(B) With respect to each drug (identified by national drug code) for which benefits are available under such plan or coverage-- ``(i) the in-network rate (expressed as a dollar amount) 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 drug; ``(ii) the average amount paid by such plan or coverage (accounting for, in a manner determined appropriate by the Secretary, rebates, discounts, price concessions, and any other remuneration specified by the Secretary) for such drug dispensed or administered during the 90-day period beginning 180 days before such date of publication to each provider that was a participating provider with respect to such drug, broken down by each such provider, unless fewer than 20 claims for such drug were submitted to such plan or coverage during such period; and ``(iii) in the case such drug is an applicable spread price drug dispensed by a pharmacy-- ``(I) a specification that such drug is such an applicable spread price drug; and ``(II) for each pharmacy that has a contractual relationship for dispensing such drug under such plan or coverage, a specification of the difference (if any) between the specified payment amount for such drug so dispensed by such pharmacy and the specified reimbursement amount for such drug so dispensed by such pharmacy. ``(C) With respect to each item or service for which benefits are available under such plan or coverage, the amount billed, and the amount allowed by the plan, for each such item or service furnished during the 6-month period beginning 9 months before the date such information is made public by a provider that was not a participating provider with respect to such item or service, broken down by each such provider, other than such an amount with respect to an item or service furnished by a provider that, during such period, submitted fewer than 11 claims for such item or service to such plan or coverage. ``(3) Manner of publication.-- ``(A) In general.--Rate and payment information required to be made available under this subsection shall be so made available in dollar amounts through separate machine-readable files (and any successor technology, as applicable, such as application programming interface technology, determined appropriate by the Secretary) corresponding to the information described in each of subparagraphs (A) through (C) of paragraph (2) that meet such requirements as specified by the Secretary (which may be so specified through subregulatory guidance). Such requirements shall ensure that such files are limited to an appropriate size, do not include disclosure of unnecessary duplicative information contained in other files made available under this subsection, are made available in a widely available format through a publicly available website that allows for information contained in such files to be compared across group health plans and group or individual health insurance coverage, and are accessible to individuals at no cost and without the need to establish a user account or provide other credentials. ``(B) Timing.--Rate and payment information-- ``(i) described in subparagraph (A) or (B) of paragraph (2) shall be made public on a quarterly basis; and ``(ii) described in subparagraph (C) of paragraph (2) shall be made public on a monthly basis. ``(4) User instructions.--Each group health plan and health insurance issuer offering group health insurance coverage shall make available to the public instructions written in plain language explaining how individuals may search for information described in paragraph (2) in files submitted in accordance with paragraph (3). The Secretary shall develop and publish through subregulatory guidance a template that such a plan may use in developing instructions for purposes of the preceding sentence. ``(5) Summary.--For each plan year beginning on or after January 1, 2028, each group health plan and health insurance issuer offering group health insurance coverage shall make public a data file, in a manner that ensures that such file may be easily downloaded and read by standard spreadsheet software and that meets such requirements as established by the Secretary, containing a summary of all rate and payment information made public by such plan or issuer with respect to such plan or coverage during such plan year. Such file shall include the following: ``(A) The mean, median, and interquartile range of the in-network rate, and the amount allowed for an item or service when not furnished by a participating provider, in effect as of the first day of such plan year for each item or service (identified by payer identifier approved or used by the Centers for Medicare & Medicaid Services) for which benefits are available under the plan or coverage, broken down by the type of provider furnishing the item or service and by the geographic area in which such item or service is furnished. ``(B) Trends in payment rates for such items and services over such plan year, including an identification of instances in which such rates have increased, decreased, or remained the same. ``(C) The name of such plan, a description of the type of network of participating providers used by such plan or coverage, and, in the case of a group health plan, a description of whether such plan is self- insured or fully-insured. ``(D) For each item or service which is paid as part of a bundled or capitated rate-- ``(i) a description of the formulae, pricing methodologies, or other information used to calculate the payment rate for such rate; and ``(ii) a list of the items and services included in such rate. ``(E) The percentage of items and services that are paid for on a fee-for-service basis and the percentage of items and services that are paid for as part of a bundled rate, capitated payment rate, or other alternative payment model. ``(d) Attestation.--Each group health plan and health insurance issuer offering group health insurance coverage shall annually submit to the Secretary an attestation of such plan's or coverage's compliance with the provisions of this section. Such attestation shall include a link to the website (or other successor technology) where rate and payment information required to be made public under subsection (c) may be accessed. ``(e) Accessibility.--A group health plan and a health insurance issuer offering group health insurance coverage shall take reasonable steps (as specified by the Secretary) to ensure that information provided in response to a request described in subsection (b), and rate and payment information made public under subsection (c), is provided in plain, easily understandable language and that interpretation, translations, and assistive services are provided to those with limited English proficiency and those with disabilities. ``(f) PBM Disclosure of Applicable Spread Price Drugs.--An entity providing pharmacy benefit management services on behalf of a group health plan or group health insurance coverage shall disclose to such plan or coverage, at such time and in such manner as specified by the Secretary to ensure that information provided under subsection (b) and rate and payment information made public under subsection (c) is timely and accurate-- ``(1) a list of drugs (identified by national drug codes) for which benefits are available under such plan that are applicable spread price drugs; and ``(2) with respect to each drug included on such list and each pharmacy with a contractual relationship for furnishing such drug under such plan or coverage, a specification of the difference (if any) between the specified payment amount for such drug so dispensed by such pharmacy and the specified reimbursement amount for such drug so dispensed by such pharmacy. ``(g) Definitions.--In this section: ``(1) Applicable spread price drug.--The term `applicable spread price drug' means, with respect to a group health plan or group health insurance coverage, a drug for which benefits are available under such plan or coverage and with respect to which, at the time a disclosure described in subsection (f) is required to be made by an entity providing pharmacy benefit management services on behalf of such plan or coverage-- ``(A) a contract is in effect between such entity and a pharmacy for the dispensing of such drug under such plan or coverage; and ``(B) the specified payment amount for such drug so dispensed is less than the specified reimbursement amount for such drug so dispensed. ``(2) In-network rate.--The term `in-network rate' means, with respect to a group health plan or group health insurance coverage and an item or service furnished by a provider that is a participating provider with respect to such plan or coverage and item or service, the contracted rate (reflected as a dollar amount) in effect between such plan or coverage and such provider for such item or service, regardless of whether such rate is calculated based on a set amount, a fee schedule, or an amount derived from another amount, or a formula, or other method. ``(3) Participating provider.--The term `participating provider' means, with respect to an item or service and a group health plan or health insurance issuer offering group health insurance coverage, a physician or other health care provider (as defined in paragraph (4)) who is acting within the scope of practice of that provider's license or certification under applicable State law and who has a contractual relationship with the plan or issuer, respectively, for furnishing such item or service under the plan or coverage, respectively. ``(4) Provider.--The term `provider' includes a health care facility and a pharmacy. ``(5) Specified payment amount.--The term `specified payment amount' means, with respect to a drug to be dispensed by a pharmacy to a participant or beneficiary of a group health plan or group health insurance coverage where such pharmacy has in effect a contract with an entity providing pharmacy benefit management services on behalf of such plan or coverage for the dispensing of such drug under such plan or coverage, the amount that such entity has agreed to pay such pharmacy for the ingredient costs and any applicable dispensing fee for such drug (or the amount that such entity has agreed to pay such pharmacy for such drug under any other compensation structure specified by the Secretary) under such contract, taking into account any cost sharing requirement applicable to such drug and participant or beneficiary. ``(6) Specified reimbursement amount.--The term `specified reimbursement amount' means, with respect to a drug to be dispensed by a pharmacy to a participant or beneficiary of a group health plan or group health insurance coverage where such pharmacy has in effect a contract with an entity providing pharmacy benefit management services on behalf of such plan or coverage for the dispensing of such drug under such plan or coverage, that amount that such plan or coverage has agreed to pay to such entity for the ingredient costs and any applicable dispensing fee for such drug (or the amount that such plan or coverage has agreed to pay such entity for such drug under any other compensation structure specified by the Secretary), taking into account any cost sharing requirement applicable to such drug and participant or beneficiary.''. (B) Clerical amendment.--The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 is amended by striking the item relating to section 719 and inserting the following new item: ``Sec. 719. Transparency in coverage.''. (b) Application Programming Interface Report.--Not later than January 1, 2028, and annually thereafter, the Secretary of Health and Human Services shall, in consultation with the Office of the National Coordinator for Health Information Technology, Department of Labor, the Department of the Treasury, and stakeholders, submit to the House Committees on Education and the Workforce, Energy and Commerce, and Ways and Means, and the Senate Committees on Finance and Health, Education, Labor, and Pensions a report on the use of standards-based application programming interfaces (in this subsection referred to as ``APIs'') to facilitate access to health care price transparency information and the interoperability of other medical information. Such report shall include an evaluation of the capacity of the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury to regulate and implement standards related to APIs and recommendations for improving such capacity. Such report shall include the following: (1) A description of current use, and proposed use, of APIs under Federal rules to facilitate interoperability, including information related to capacity constraints within the agencies, barriers to adoption, privacy and security, administrative burdens and efficiencies, care coordination, and levels of compliance. (2) A description of the feasibility of agency participation in the development of APIs to enable application access to price transparency data under the amendments made by subsection (a). (3) A specification of the timeline for which such data standards can be required to make such data accessible via an API. (4) An analysis of the benefits and challenges of implementing standards-based APIs for price transparency data, including the ability for consumers to access rate and payment information and the amount of cost-sharing (including deductibles, copayments, and coinsurance) under the consumer's plan through third-party internet-based tools and applications. (5) An analysis of the impact that APIs which provide real- time access to pricing and cost-sharing information may have in increasing the amount of services shoppable for individuals, such as by standardizing more health care spend via episode bundles. (6) An analysis of which health care items and services may be useful under API, such as those for which prices change with the greatest frequency. (7) An analysis of the cost of API standards implementation on issuers, employers, and other private-sector entities. (8) An analysis of the ability of State regulators to enforce API standards and the costs to the Federal Government and States to regulate and enforce API standards. (9) An analysis of the interaction with API standards and Federal health information privacy standards. (c) Provider Tool Report.-- (1) In general.--Not later than 1 year after the date of the enactment of this Act, The Secretary of Health and Human Services, acting through the Administrator of the Centers for Medicare & Medicaid Services, shall, in consultation with stakeholders, conduct a study and submit to the House Committees on Education and the Workforce, Energy and Commerce, and Ways and Means, and the Senate Committees on Finance and Health, Education, Labor, and Pensions a report on the usefulness and feasibility of the establishment of a provider tool by a group health plan, or a health insurance issuer offering group or individual health insurance coverage, in facilitating the provision of information made available pursuant to the amendments made by subsection (a). Such report shall include the following: (A) A description of the feasibility of establishing a requirement for the various types of plans and coverage to offer such a provider tool, including any challenges to establishing a provider tool using the same technology platform as the self- service tool described in such amendments. (B) An evaluation on the usefulness of a provider tool to aid patient-decision making and how such tool would coordinate with other information available to a patient and their provider under other Federal requirements in place or under consideration. (C) An evaluation of whether the information provided by such tool would be duplicative of the advanced explanation of benefits required under Federal law or any other existing requirement. (D) A description of the usability and expected utilization of such tool among providers, including among different provider types. (E) An analysis of the impact of a provider tool in value-based care arrangements. (F) An analysis on the potential impact of the provider tool on-- (i) patients' out-of-pocket spending; (ii) plan design, including impacts on cost-sharing requirements; (iii) care coordination and quality; (iv) plan premiums; (v) overall health care spending and utilization; and (vi) health care access in rural areas. (G) An analysis of the feasibility of a provider tool to include additional functionality to facilitate and improve the administration of the requirements on providers to submit notifications to such plan or coverage under section 2799B-6 of the Public Health Service Act and the requirements on such plan or coverage to provide an advanced explanation of benefits to individuals under section 2799A-1(f) of such Act. (H) An analysis of which health care items and services, would be most useful for providers utilizing a provider tool. (I) An analysis of rulemaking required to ensure such a tool complies with federal health information privacy standards. (J) An analysis of the burden and cost of the creation of a provider tool by plans and coverage on providers, issuers, employers, and other private-sector entities. (K) An analysis of the ability of state regulators to enforce provider tool standards and the costs to the Department and states to regulate and enforce provider tool standards. (2) Definition.--The term ``provider tool'' means a tool designed to facilitate the provision of information made available pursuant to the amendments made by subsection (a) and established by a group health plan or a health insurance issuer offering group or individual health insurance coverage that allows providers to access the information such plan or coverage must provide through the self-service tool described in such amendments to an individual with whom the provider is actively treating at the time of such request, upon the request of the provider, and with the consent of such individual. (d) Reports.-- (1) Compliance.--Not later than January 1, 2029, the Comptroller General of the United States shall submit to Congress a report containing-- (A) an analysis of compliance with the amendments made by this section; (B) an analysis of enforcement of such amendments by the Secretaries of Health and Human Services, Labor, and the Treasury; (C) recommendations relating to improving such enforcement; and (D) recommendations relating to improving public disclosure, and public awareness, of information required to be made available by group health plans and health insurance issuers pursuant to such amendments. (2) Prices.--Not later than January 1, 2029, and biennially thereafter, the Secretaries of Health and Human Services, Labor, and the Treasury shall jointly submit to Congress a report containing an assessment of differences in negotiated prices (and any trends in such prices) in the private market between-- (A) rural and urban areas; (B) the individual, small group, and large group markets; (C) consolidated and nonconsolidated health care provider areas (as specified by the Secretary of Health and Human Services); (D) nonprofit and for-profit hospitals; (E) nonprofit and for-profit insurers; and (F) insurers serving local or regional areas and insurers serving multistate or national areas. (e) Quality Report.--Not later than 1 year after the date of enactment of this subsection, the Secretaries of Health and Human Services, Labor, and the Treasury shall jointly submit to Congress a report on the feasibility of including data relating to the quality of health care items and services with the price transparency information required to be made available under the amendments made by subsection (a). Such report shall include recommendations for legislative and regulatory actions to identify appropriate metrics for assessing and comparing quality of care. (f) Continued Applicability of Rules for Previous Years.--Nothing in the amendments made by subsection (a) may be construed as affecting the applicability of the rule entitled ``Transparency in Coverage'' published by the Department of the Treasury, the Department of Labor, and the Department of Health and Human Services on November 12, 2020 (85 Fed. Reg. 72158), for any plan year beginning before January 1, 2028. <all>