[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4822 Introduced in House (IH)]
<DOC>
118th CONGRESS
1st Session
H. R. 4822
To improve price transparency with respect to certain health care
services, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 24, 2023
Mr. Smith of Missouri introduced the following bill; which was referred
to the Committee on Energy and Commerce, and in addition to the
Committees on Ways and Means, Education and the Workforce, and the
Budget, for a period to be subsequently determined by the Speaker, in
each case for consideration of such provisions as fall within the
jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To improve price transparency with respect to certain health care
services, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Health Care Price
Transparency Act of 2023''.
(b) Table of Contents.--The table of contents for this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--HEALTH CARE PRICE TRANSPARENCY FOR PATIENTS
Sec. 101. Requiring certain facilities under the Medicare program to
disclose certain information relating to
charges and prices.
Sec. 102. Promoting group health plan price transparency.
Sec. 103. Oversight of pharmacy benefits manager services.
Sec. 104. Reports on health care transparency tools and data
requirements.
Sec. 105. Report on integration in Medicare.
TITLE II--FAIR PRICES FOR PATIENTS
Sec. 201. Limitation on cost sharing to net price amount under Medicare
part D.
Sec. 202. Requiring a separate identification number and an attestation
for each off-campus outpatient department
of a provider.
Sec. 203. Parity in Medicare payments for hospital outpatient
department services furnished off-campus.
TITLE III--PATIENT-FOCUSED INVESTMENTS
Sec. 301. Establishing requirements with respect to the use of prior
authorization under Medicare Advantage
plans.
Sec. 302. Extension of certain direct spending reductions.
TITLE I--HEALTH CARE PRICE TRANSPARENCY FOR PATIENTS
SEC. 101. REQUIRING CERTAIN FACILITIES UNDER THE MEDICARE PROGRAM TO
DISCLOSE CERTAIN INFORMATION RELATING TO CHARGES AND
PRICES.
(a) In General.--Part E of title XVIII of the Social Security Act
(42 U.S.C. 1395x et seq.) is amended by adding at the end the following
new section:
``SEC. 1899C. HEALTH CARE PROVIDER PRICE TRANSPARENCY.
``(a) Hospital Price Transparency.--
``(1) In general.--Beginning January 1, 2026, each
specified hospital (as defined in paragraph (6)) 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
paragraph is, with respect to a specified 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) one or more lists, in a format
specified by the Secretary (which may be a
machine-readable format), of the hospital's
standard charges (including the information
described in subparagraph (B)) for each item
and service furnished by such hospital; and
``(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.
``(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 specified
hospital, the following:
``(i) A description of each item or
service, accompanied by, as applicable, the
Healthcare Common Procedure Coding System code,
the diagnosis-related group, the national drug
code, or other identifier used or approved by
the Centers for Medicare & Medicaid Services.
``(ii) The gross charge, expressed as a
dollar amount, for each such item or service,
when provided in, as applicable, the inpatient
setting and outpatient department setting.
``(iii) The discounted cash price,
expressed as a dollar amount, for each such
item or service when provided in, as
applicable, the inpatient setting and
outpatient department setting (or, in the case
no discounted cash price is available for an
item or service, the median price charged by
the hospital for such item or service when
provided in such settings for the previous
three years, expressed as a dollar amount).
``(iv) Any other information the Secretary
may require for purposes of promoting public
awareness of specified hospital standard
charges or prices in advance of receiving an
item or service from such a hospital, except
information that is duplicative of any other
reporting requirement under this section. Such
information may include any current payer-
specific negotiated charges, 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.
``(C) Method and format.--Not later than January 1,
2026, the Secretary shall establish one or more methods
and formats for specified facilities to use in
compiling and making public standard charges and prices
(as applicable) pursuant to subparagraph (A). Any such
method and format--
``(i) 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;
``(ii) shall meet such standards as
determined appropriate by the Secretary in
order to ensure the accessibility and usability
of such charges and prices; and
``(iii) shall be updated as determined
appropriate by the Secretary, in consultation
with stakeholders.
``(3) Deemed compliance with shoppable services requirement
for hospitals with a price estimator tool.--
``(A) In general.--With respect to each year until
the effective date of regulations implementing the
provisions of sections 2799A-1(f) and 2799B-6 of the
Public Health Service Act (relating to advanced
explanations of benefits), including regulations on
establishing data transfer standards to effectuate such
provisions, a specified hospital shall be deemed to
have complied with the requirement described in
paragraph (2)(A)(ii)(I) (relating to shoppable
services) if such hospital maintains a price estimator
tool described in subparagraph (B).
``(B) Price estimator tool described.--For purposes
of subparagraph (A), the price estimator tool described
in this subparagraph is, with respect to a specified
hospital, a tool that meets the following requirements:
``(i) Such tool allows an individual to
immediately obtain a price estimate (taking
into account whether such individual is covered
under any plan, coverage, or program described
in clause (iv)(III)) and the discounted cash
price charged by a specified hospital, for each
Centers for Medicare & Medicaid Services-
specified shoppable service that is furnished
by such hospital, and for each additional
shoppable service as such hospital may select,
such that price estimates are available through
such tool for at least 300 shoppable services
(or for all such services, if such hospital
furnishes fewer than 300 shoppable services).
``(ii) Such tool allows an individual to
obtain such an estimate by billing code and by
service description.
``(iii) Such tool is prominently displayed
on the public internet website of such
hospital.
``(iv) Such tool does not require an
individual seeking such an estimate to create
an account or otherwise input personal
information, except that such tool may require
that such individual provide information
specified by the Secretary, which may include
the following:
``(I) The name of such individual.
``(II) The date of birth of such
individual.
``(III) In the case such individual
is covered under a group health plan,
group or individual health insurance
coverage, a Federal health care
program, or the program established
under chapter 89 of title 5, United
States Code, an identifying number
assigned by such plan, coverage, or
program to such individual.
``(IV) In the case of an individual
described in subclause (III), an
indication as to whether such
individual is the primary insured
individual under such plan, coverage,
or program (and, if such individual is
not the primary insured individual, a
description of the individual's
relationship to such primary insured
individual).
``(V) Any other information
specified by the Secretary.
``(v) Such tool contains a statement
confirming the accuracy and completeness of
information presented through such tool as of
the date such request is made.
``(vi) Such tool meets any other
requirement specified by the Secretary.
``(4) Monitoring compliance.--The Secretary shall, through
notice and comment rulemaking and in consultation with the
Inspector General of the Department of Health and Human
Services, establish a process to monitor compliance with this
subsection. Such process shall ensure that each specified
hospital's compliance with this subsection is reviewed not less
frequently than once every 3 years.
``(5) Enforcement.--
``(A) In general.--In the case of a specified
hospital that fails to comply with the requirements of
this subsection--
``(i) the Secretary shall notify such
hospital 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
hospital 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 law, a specified
hospital 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 such a hospital that has submitted
a corrective action plan described in
subparagraph (A)(ii) in response to a request
so described, by the date that is 90 days after
the Secretary identifies the failure of such
hospital to satisfactorily complete such
corrective action plan) shall be subject to a
civil monetary penalty of an amount specified
by the Secretary for each subsequent day during
which such failure is ongoing. Such amount
shall not exceed--
``(I) in the case of a specified
hospital that is a hospital or critical
access hospital with 30 or fewer beds,
$300 per day; and
``(II) in the case of any specified
hospital and except as provided in
clause (iii), $2,000,000 for a 1-year
period.
``(ii) Increase authority.--In applying
this subparagraph with respect to violations
occurring in 2027 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 that is a hospital
or critical access hospital with 30 or
fewer beds under clause (i)(I);
``(II) the limitation on the amount
of any penalty applicable for a 1-year
period under clause (i)(II); and
``(III) the limitation on the
increase of any penalty applied under
clause (iii).
``(iii) Persistent noncompliance.--In the
case of a specified hospital (other than a
specified hospital that is a hospital or
critical access hospital with 30 or fewer beds)
that the Secretary has determined to be
knowingly and willfully noncompliant with the
provisions of this subsection two or more times
during a 1-year period, the Secretary may
increase any penalty otherwise applicable under
this subparagraph by not more than $1,000,000
and may require such hospital to complete such
additional corrective actions plans as the
Secretary may specify.
``(iv) 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 subparagr