Strengthening health coverage transparency requirements

(a) Transparency in coverage Section 2715A of the Public Health Service Act (42 U.S.C. 300gg–15a) is amended— (1) by striking A Group health and inserting the following: (a) In general A group health; and (2) by adding at the end the following: (b) Additional transparency requirements (1) Specified information required (A) In general A group health plan or health insurance issuer offering coverage in the individual or group market shall provide to each participant, beneficiary, or enrollee, at the time of enrollment in the plan or coverage, the information described in subparagraph (B). (B) Information required For purposes of subparagraph (A), the information specified in this subparagraph is, with respect to benefits available under the plan or coverage for an item or service furnished by a health care provider, the following (or other information as determined appropriate by the Secretary): (i) If such provider is an in-network provider with respect to such item or service, the in-network rate (as defined in paragraph (5)) for such item or service. (ii) If such provider is not described in clause (i), the out-of-network allowed amount (as such term is defined for purposes of section 147.210(a)(2)(xvii) of title 45, Code of Federal Regulations) for such item or service that the plan or coverage will pay without regard to the amount in clause (iii). (iii) The amount of cost-sharing liability (including deductibles, copayments, and coinsurance) that the individual will incur for such item or service based on the information available to the plan or coverage at the time the request is made (which, in the case such item or service is to be furnished by a provider described in clause (ii), shall be calculated using the maximum amount described in such clause). (iv) The accumulated amounts with respect to any deductible or out-of-pocket maximum under the plan or coverage reflected in the plan’s or coverage's records at the time the request is made (broken down, in the case separate deductibles or maximums apply to separate individuals enrolled in the plan or coverage, by such separate deductibles or maximums, in addition to any cumulative deductible or maximum). (v) In the case such plan or coverage 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 reflected in the plan’s or coverage's records at the time the request is made. (vi) Information about any utilization management requirements, such as prior authorization, concurrent review, step therapy, fail first, or similar requirements applicable to coverage of such item or service under such plan or coverage, including information regarding utilization management practices and determinations, including aggregate information related to approval and denial rates, associated timelines, and appeals, as determined appropriate by the Secretary. (C) Self-service tool For purposes of subparagraph (A), a self-service tool established by a health plan meets the requirements of this subparagraph if such tool— (i) is based on an internet website; (ii) provides for real-time responses to requests described in such subparagraph; (iii) is updated in a manner such that the information is accurate based on the information available to the plan or coverage at the time the request is made; (iv) allows such a request to be made for information with respect to an item or service furnished by— (I) a specific provider that is an in-network provider with respect to such item or service; or (II) all providers that are in-network providers with respect to such plan or coverage and such item or service; (v) provides that such a request may be made for information with respect to an item or service through use of— (I) the billing code for such item or service; or (II) through use of a descriptive term for such item or service; and (vi) is made available in plain language, without subscription or other fee. (D) Nonduplication A group health plan or health insurance issuers shall be deemed to be in compliance with this paragraph if such plan or issuer has a tool in place under section 2799A–4. (2) Rate and payment information (A) In general Beginning January 1 of the year that begins on or after the date that is 1 year after the date of enactment of the Health CARE Act of 2026, and every quarter thereafter (if there have been any changes to the rate and payment information described in subparagraphs (B) and (C), each group health plan or health insurance issuer offering coverage in the group or individual market shall make available to the public, the rate and payment information described in subparagraph (B) in accordance with subparagraph (C)). (B) Rate and payment information described For purposes of subparagraph (A), the rate and payment information described in this subparagraph is, with respect to a plan or coverage, the following: (i) With respect to each item or service for which benefits are available under such plan or coverage, excluding those included in clause (ii), identified by CPT, HCPCS, DRG, or other applicable nationally recognized identifier, including any applicable code modifiers, and accompanied by a plain language description of the item or service, the in-network rate (expressed as a dollar amount or percentage of charges, unless otherwise specified by the Secretary), including the individual and total amounts for any bundled rates, in effect as of the date of the submission of such information with each provider (identified by national provider identifier) that is an in-network provider with respect to such item or service, other than such a rate in effect with a provider that an issuer has determined based on factors determined by the Secretary (such as medical specialty) that it is unlikely that the provider would be reimbursed for the item or service. (ii) With respect to each drug and biologic (identified by National Drug Code, J-code, or other commonly recognized billing code used for drugs) for which benefits are available under such plan or coverage, the in-network rate (expressed as a dollar amount or percentage of charges, unless otherwise specified by the Secretary) in effect as of the first day of the quarter in which such information is made public with each pharmacy or other prescription drug dispenser that is an in-network pharmacy or other prescription drug dispenser with respect to such drug. (iii) With respect to each item or service for which benefits are available under such plan or coverage (expressed as a dollar amount), identified by CPT, DRG, HCPCS, or other applicable nationally recognized identifier, including any applicable code modifiers, and accompanied by a brief description of the item or service, the amount billed or charged by the provider, and the amount allowed by the plan or coverage, for each such item or service furnished during a representative lookback window established by the Secretary by each provider that was an out-of-network provider with respect to such item or service, broken down by each such provider (identified by national provider identifier), other than items and services with respect to which not fewer than 11 claims for such item or service were submitted to such plan during such period. (C) Manner of submission Rate and payment information required to be submitted and made available under this paragraph shall be so submitted and so made available as follows: (i) Information shall be contained in at least 3 separate machine-readable files corresponding to the information described in each of clauses (i) through (iii) of subparagraph (B) that meet such requirements as specified by the Secretary through rulemaking, in consultation with the Secretaries of Labor and the Treasury, to apply comparable requirements to group health plans and health insurance coverage and to entities providing benefit management or other third-party administration services on a contractual basis with a group health plan or coverage. (ii) Requirements specified by the Secretary through rulemaking (or subregulatory guidance) shall ensure the following: (I) Such files are made available in a widely available format that allows for information contained in such files to be compared across plans and coverage and are freely accessible to individuals at no cost and without the need to establish a user account or provide other credentials. (II) Each such file includes each of the following data elements: (aa) A numerical identifier for the group health plan or health insurance issuer (such as a Health Insurance Oversight System identifier). (bb) A plain-language description of the item or service (including, for drugs, the proprietary and nonproprietary name assigned). (cc) The billing code, including any applicable modifiers, associated with such item or service, including the Healthcare Common Procedure Coding System code, diagnosis-related group, national drug code, or other commonly recognized code set. (dd) The place of service code. (ee) The National Provider Identifier and provider Tax Identification Number. (iii) The rate and payment information disclosed under clauses (i) through (iii) of subparagraph (B) shall be separately delineated for each item or service, regardless of whether such item or service is reimbursed as a part of a bundle, episode, or other grouping of items and services. (iv) An officer or executive of competent authority shall attest to the accuracy and completeness of information submitted and made available under this subparagraph. In the case of a plan or coverage that relies on a third-party administrator or other service provider to compile the information submitted and made available under this subparagraph, such plan or coverage may satisfy the requirement under this clause by obtaining such an attestation from the third-party administrator or other service provider. Such attestation shall be subject to enforcement under paragraph (6). (3) Ownership information Beginning January 1 of the year that begins on or after the date that is 1 year after the date of enactment of the Health CARE Act of 2026, and every quarter thereafter (if there have been any changes in the required information), each group health plan or health insurance issuer offering coverage in the individual or group market shall submit to the Secretary, the applicable State authority, and make available to the public, the name and business address of each person or entity that, with respect to such plan or coverage— (A) has an ownership or investment interest; (B) has a controlling interest; (C) is a management services organization; or (D) is a significant equity investor. (4) Enforcement (A) In general Each year, the Secretary shall audit the machine-readable files required by paragraph (2)(B) posted by not fewer than 50 group health plans or health insurance issuers for compliance with format and accessibility standards. (B) Notification and request for corrective action In the case of a group health plan or health insurance issuer that fails to comply with the requirements of this paragraph, not later than 30 days after the date on which the Secretary determines such failure exists, the Secretary shall submit to such plan or issuer a notification of such determination, which shall include a request for a corrective action plan to comply with such requirements. (C) Civil monetary penalty A plan or issuer that has received a request for a corrective action plan under subparagraph (B) and fails to comply with the requirements of this paragraph by the date that is 30 days after such request is made shall be subject to a civil monetary penalty of an amount specified by the Secretary for each day (beginning with the day on which such health plan or health insurance issuer was failing to comply with such paragraph) during which such failure was ongoing. Such amount shall not exceed $300 per participant, beneficiary, or covered individual per day or $10,000,000, whichever is lesser. (5) Definitions In this subsection: (A) In-network provider The term in-network provider has the meaning given such term in section 54.9815–2715A1(a)(2)(xii) of title 26, Code of Federal Regulations. (B) In-network rate The term in-network rate means, with respect to a health plan and an item or service furnished by a provider that is a participating provider with respect to such plan and item or service, the contracted rate in effect between such plan and such provider for such item or service. If the rate is based on an algorithm, percentage of another amount, or other formula or criteria, the health plan also shall disclose such algorithm, percentage, formula, or criteria as set forth in its contract and any other terms, schedules, exhibits, data, or other information referenced in any such contract as shall be required to determine and disclose the negotiated rate. (6) Rulemaking (A) In general The Secretary shall implement this subsection through notice and comment rulemaking in accordance with section 553 of title 5, United States Code. The Secretary may implement the manner of submission of data described in paragraph (2)(C) through subregulatory guidance. (B) Regulations Regulations promulgated pursuant to this subsection shall provide the following: (i) The Secretary shall annually audit the machine-readable files required by paragraph (2)(B) posted by not fewer than 50 group health plans or health insurance issuers for compliance with format and accessibility standards. (ii) The Secretary of Labor shall annually audit the machine-readable files required by paragraph (2)(B) posted by not fewer than 250 group health plans or service providers furnishing third-party administrator services to a group health plan for compliance with format and accessibility standards. (iii) The Secretary of Health and Human Services, in conjunction with the Secretary of Labor and the Secretary of the Treasury, shall annually issue a report to Congress that includes findings, conclusions, and enforcement actions taken based on audits of the machine-readable files. Such report shall be provided no later than July 1 following the calendar year during which the audits were completed. The Secretary of Health and Human Services shall make such report to Congress accessible to the public.. (b) Effective date (1) In general The amendments made by subsections (a) and (b) shall apply beginning January 1 of the year that begins on or after the date that is 1 year after the date of enactment of the Health CARE Act of 2026. (2) Continued applicability of rules for previous years Nothing in the amendments made by this section may be construed as affecting the applicability of the rule entitled Transparency in Coverage published by the Department of the Treasury, the Department of Labor, and the Department of Health and Human Services on November 12, 2020 (85 Fed. Reg. 72158), or amendments made to such rule that are applicable before the date of enactment of the Health CARE Act of 2026.