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 2029 (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, 2029.; 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, 2029, 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) Other information determined appropriate by the Secretary. (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) is made available in plain language at no cost; (C) provides for real-time responses to requests described in paragraph (1); (D) is updated in a manner such that information provided through such tool is timely and accurate at the time such request is made; (E) 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) nonspecific providers located in a relevant geographic region that are not participating providers with respect to such item or service; (F) 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 (G) meets any other requirement determined appropriate by the Secretary, including requirements to ensure the accessibility and usability of information provided through such tool. (c) Rate and payment information (1) In general For plan years beginning on or after January 1, 2029, each group health plan (other than a grandfathered health plan (as defined in section 1251(e) of the Patient Protection and Affordable Care Act) or a church plan (as defined in section 414(e))) 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 (other than, in the case that such plan provides benefits for such item or service only when furnished by a specific type of provider, such a participating provider who is not such type of provider (referred to in this subparagraph as an excluded provider)); and (ii) with respect to each such participating provider (other than a provider that is an excluded provider with respect to such item or service), 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 for which payment was made (in whole or in part) 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 for which, during such period, fewer than 11 claims were made under such plan. In determining the number of claims made under such plan with respect to an item or service during such period for purposes of the preceding sentence, such number shall be deemed to include all claims for such item or service made during such period under all group health plans offered in the same insurance market (specified in subclause (I), (II), (III), of section 9816(a)(3)(E)(iv)) by the sponsor of the plan at issue. In the case that a specific dollar amount for an in-network rate required to be made available pursuant to this subsection with respect to an item or service cannot be determined prospectively on the basis that such rate is determined as a percentage of the billed charges for such item or service, such percentage and the median amount recognized by such plan as payment for such item or service with respect to claims for such item or service submitted by participating providers during the period described in subparagraph (A)(ii) shall be reported by such plan in lieu of such rate. Such plan shall identify that such median amount represents an estimate of such in-network rate for such item or service. (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), including requirements relating to whether such information should be so made available on the plan or coverage level, with respect to individual provider networks, or aggregated in such manner as specified by the Secretary. 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 or undertake other steps as may be specified by the Secretary. (B) Timing Rate and payment information described in paragraph (2) shall be made public on a quarterly 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, 2029, 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 A group health plan shall annually submit to the Secretary an attestation, signed by the chief executive officer, chief financial officer, or other comparable official (as specified by the Secretary) of such plan, of such plan’s compliance with the provisions of this section and that information made available under this section is true, accurate, and complete. Such attestation shall, except in the case of a grandfathered health plan (as defined in section 1251(e) of the Patient Protection and Affordable Care Act) or a church plan (as defined in section 414(e)), 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) 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 rate and payment information is made public by such plan under subsection (c)— (A) a contract is in effect between an entity providing pharmacy benefit management services on behalf of such plan and a pharmacy for the dispensing of such drug under such 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, the 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 2029 (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, 2029.; 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, 2029, 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) Other information determined appropriate by the Secretary. (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) is made available in plain language at no cost; (C) provides for real-time responses to requests described in paragraph (1); (D) is updated in a manner such that information provided through such tool is timely and accurate at the time such request is made; (E) 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) nonspecific providers located in a relevant geographic region that are not participating providers with respect to such item or service; (F) 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 (G) meets any other requirement determined appropriate by the Secretary, including requirements to ensure the accessibility and usability of information provided through such tool. (c) Rate and payment information (1) In general For plan years beginning on or after January 1, 2029, 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) and other than such an issuer offering group health insurance coverage in connection with a church plan (as defined in section 414(e) of the Internal Revenue Code of 1986)) 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 (other than, in the case that such plan or coverage provides benefits for such item or service only when furnished by a specific type of provider, such a participating provider who is not such type of provider (referred to in this subparagraph as an excluded provider)); and (ii) with respect to each such participating provider (other than a provider that is an excluded provider with respect to such item or service), 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 for which payment was made (in whole or in part) 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 or coverage, 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 for which, during such period, fewer than 11 claims were made under such plan or coverage. In determining the number of claims made under such plan or coverage with respect to an item or service during such period for purposes of the preceding sentence, such number shall be deemed to include all claims for such item or service made during such period under all group health plans and health insurance coverage offered in the same insurance market (specified in subclause (I), (II), (III), or (IV) of section 2799A–1(a)(3)(E)(iv)) by the sponsor or issuer (as applicable) of the plan or coverage at issue. In the case that a specific dollar amount for an in-network rate required to be made available pursuant to this subsection with respect to an item or service cannot be determined prospectively on the basis that such rate is determined as a percentage of the billed charges for such item or service, such percentage and the median amount recognized by such plan or coverage as payment for such item or service with respect to claims for such item or service submitted by participating providers during the period described in subparagraph (A)(ii) shall be reported by such plan in lieu of such rate. Such plan or coverage shall identify that such median amount represents an estimate of such in-network rate for such item or service. (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), including requirements relating to whether such information should be so made available on the plan or coverage level, with respect to individual provider networks, or aggregated in such manner as specified by the Secretary. 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 described in paragraph (2) shall be made public on a quarterly 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, 2029, 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, signed by the chief executive officer, chief financial officer, or other comparable official (as specified by the Secretary) of such plan or issuer, of such plan’s or coverage’s compliance with the provisions of this section and that information made available under this section is true, accurate, and complete. Such attestation shall, except in the case of a grandfathered health plan (as defined in section 1251(e) of the Patient Protection and Affordable Care Act) or in the case of such an issuer offering group health insurance coverage in connection with a church plan (as defined in section 414(e) of the Internal Revenue Code of 1986), 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) 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 rate and payment information is made public by such plan under subsection (c)— (A) a contract is in effect between an entity providing pharmacy benefit management services on behalf of such plan or coverage and a pharmacy for the dispensing of such drug under such plan or 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, the amount that such plan or coverage has agreed to pay to such entity for the ingredient costs and any applicable dispensing fee for such drug (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 2029 (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, 2029.; 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, 2029, 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) Other information determined appropriate by the Secretary. (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) is made available in plain language at no cost; (C) provides for real-time responses to requests described in paragraph (1); (D) is updated in a manner such that information provided through such tool is timely and accurate at the time such request is made; (E) 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) nonspecific providers located in a relevant geographic region that are not participating providers with respect to such item or service; (F) 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 (G) meets any other requirement determined appropriate by the Secretary, including requirements to ensure the accessibility and usability of information provided through such tool. (c) Rate and payment information (1) In general For plan years beginning on or after January 1, 2029, 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 (other than, in the case that such plan or coverage provides benefits for such item or service only when furnished by a specific type of provider, such a participating provider who is not such type of provider (referred to in this subparagraph as an excluded provider)); and (ii) with respect to each such participating provider (other than a provider that is an excluded provider with respect to such item or service), 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 for which payment was made (in whole or in part) 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 or coverage, 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 for which, during such period, fewer than 11 claims were made under such plan or coverage. In determining the number of claims made under such plan or coverage with respect to an item or service during such period for purposes of the preceding sentence, such number shall be deemed to include all claims for such item or service made during such period under all group health plans and health insurance coverage offered in the same insurance market (specified in subclause (I), (II), (III), or (IV) of section 716(a)(3)(E)(iv)) by the sponsor or issuer (as applicable) of the plan or coverage at issue. In the case that a specific dollar amount for an in-network rate required to be made available pursuant to this subsection with respect to an item or service cannot be determined prospectively on the basis that such rate is determined as a percentage of the billed charges for such item or service, such percentage and the median amount recognized by such plan or coverage as payment for such item or service with respect to claims for such item or service submitted by participating providers during the period described in subparagraph (A)(ii) shall be reported by such plan or coverage in lieu of such rate. Such plan or coverage shall identify that such median amount represents an estimate of such in-network rate for such item or service. (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), including requirements relating to whether such information should be so made available on the plan or coverage level, with respect to individual provider networks, or aggregated in such manner as specified by the Secretary. 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 described in paragraph (2) shall be made public on a quarterly 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, 2029, 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, signed by the chief executive officer, chief financial officer, or other comparable official (as specified by the Secretary) of such plan or issuer, of such plan’s or coverage’s compliance with the provisions of this section and that information made available under this section is true, accurate, and complete. Such attestation shall, except in the case of a grandfathered health plan (as defined in section 1251(e) of the Patient Protection and Affordable Care Act), 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) 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 rate and payment information is made public by such plan under subsection (c)— (A) a contract is in effect between an entity providing pharmacy benefit management services on behalf of such plan or coverage and a pharmacy for the dispensing of such drug under such plan or 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, the amount that such plan or coverage has agreed to pay to such entity for the ingredient costs and any applicable dispensing fee for such drug (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, 2029, 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, 2029.