Text of US SB 3389 (2025)

II 119TH CONGRESS 1ST SESSION S. 3389 To lower health care costs for Americans. IN THE SENATE OF THE UNITED STATES DECEMBER 9, 2025 Mr. MARSHALL introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To lower health care costs for Americans. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 3 (a) SHORT TITLE.—This Act may be cited as the 4 ‘‘Lowering Health Care Costs for Americans Act’’. 5 (b) TABLE OF CONTENTS.—The table of contents for 6 this Act is as follows: 7 Sec. 1. Short title; table of contents. TITLE I—GENERAL PROVISIONS Sec. 101. Minimum monthly premium payments. Sec. 102. Requiring biometric and ID verification. Sec. 103. Facilitating enrollment in and payment into Healthcare Affordability Accounts. Sec. 104. Healthcare Affordability Accounts. Sec. 105. Extension of temporary enhanced premium credits. VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6211 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 2 •S 3389 IS Sec. 106. Special rules relating to coverage of abortion services. Sec. 107. Special rules relating to credit for plans covering abortion services. Sec. 108. Reporting of health insurance coverage. Sec. 109. Exclusion of gender transition procedures from coverage under quali- fied health plans. Sec. 110. Funding cost sharing reduction payments. Sec. 111. Waivers for State innovation. TITLE II—HOSPITAL TRANSPARENCY REQUIREMENTS Sec. 201. Strengthening hospital price transparency requirements. Sec. 202. Increasing price transparency of clinical diagnostic laboratory tests. Sec. 203. Imaging transparency. Sec. 204. Ambulatory surgical center price transparency requirements. Sec. 205. Strengthening health coverage transparency requirements. Sec. 206. Increasing group health plan access to health data. Sec. 207. Oversight of administrative service providers. Sec. 208. State preemption only in event of conflict. Sec. 209. Requirement for explanation of benefits. Sec. 210. Provision of itemized bills. TITLE I—GENERAL PROVISIONS 1 SEC. 101. MINIMUM MONTHLY PREMIUM PAYMENTS. 2 (a) IN GENERAL.—Section 36B(b) of the Internal 3 Revenue Code of 1986 is amended by adding at the end 4 the following new paragraph: 5 ‘‘(4) LIMITATION.—Notwithstanding para- 6 graphs (2) and (3), in no case shall the premium as- 7 sistance amount with respect to any coverage month 8 exceed the excess (if any) of the amount determined 9 under paragraph (2)(A) over— 10 ‘‘(A) in the case of a taxpayer whose 11 household income (expressed as a percent of the 12 poverty line) is less than 200 percent, $10, 13 ‘‘(B) in the case of a taxpayer whose 14 household income (expressed as a percent of the 15 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 3 •S 3389 IS poverty line) is not less than 200 percent, and 1 less than 300 percent, $20, 2 ‘‘(C) in the case of a taxpayer whose 3 household income (expressed as a percent of the 4 poverty line) is not less than 300 percent, and 5 less than 400 percent, $30, and 6 ‘‘(D) in the case of a taxpayer whose 7 household income (expressed as a percent of the 8 poverty line) is not less than 400 percent, 9 $40.’’. 10 (b) EFFECTIVE DATE.—The amendment made by 11 this section shall apply to taxable years beginning after 12 December 31, 2025. 13 SEC. 102. REQUIRING BIOMETRIC AND ID VERIFICATION. 14 Section 1411(b)(1) of Patient Protection and Afford- 15 able Care Act (42 U.S.C. 18081(b)(1)) is amended— 16 (1) in subparagraph (A), by striking ‘‘; and’’ 17 and inserting a semicolon; 18 (2) by redesignating subparagraph (B) as sub- 19 paragraph (C); and 20 (3) by inserting after subparagraph (A) the fol- 21 lowing: 22 ‘‘(B) government-issued photo identifica- 23 tion for each enrollee over the age of 18, and 24 any other documentation as the Administrator 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 4 •S 3389 IS of the Centers for Medicare & Medicaid Serv- 1 ices may require for purposes of enrollment 2 verification; and’’. 3 SEC. 103. FACILITATING ENROLLMENT IN AND PAYMENT 4 INTO HEALTHCARE AFFORDABILITY AC- 5 COUNTS. 6 (a) IN GENERAL.—Section 1311 of the Patient Pro- 7 tection and Affordable Care Act (42 U.S.C. 18031) is 8 amended— 9 (1) in subsection (b)(1)— 10 (A) in subparagraph (B), by striking 11 ‘‘and’’ at the end; 12 (B) by redesignating subparagraph (C) as 13 subparagraph (D); and 14 (C) by inserting after subparagraph (B) 15 the following: 16 ‘‘(C) in the case of plan years beginning 17 after December 31, 2026, and before January 18 1, 2032, facilitates enrollment in Healthcare 19 Affordability Accounts described in section 20 223(i) of the Internal Revenue Code of 1986, 21 for qualified individuals who purchase qualified 22 health plans and are eligible for premium tax 23 credits under section 36B; and’’; 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 5 •S 3389 IS (2) by adding at the end of subsection (c) the 1 following: 2 ‘‘(8) ENROLLMENT IN HEALTHCARE AFFORD- 3 ABILITY ACCOUNTS.—The Secretary shall establish a 4 procedure for notifying qualified individuals who 5 purchase qualified health plans and who are eligible 6 for a premium tax credit under section 36B of the 7 Internal Revenue Code of 1986 of the need to enroll 8 in a Healthcare Affordability Account described in 9 section 223(i) of such Code, in order to receive such 10 credit, for plan years beginning after December 31, 11 2026, and before January 1, 2032.’’; and 12 (3) in subsection (d)(4)(G), by inserting ‘‘, and, 13 for plan years beginning after December 31, 2026, 14 and before January 1, 2032, make available to any 15 individual qualifying for such a tax credit, a link to 16 the application on the website of the Department of 17 the Treasury for enrollment in a Healthcare Afford- 18 ability Account described in section 223(i) of the In- 19 ternal Revenue Code of 1986’’ before the semicolon 20 at the end. 21 (b) PAYMENT OF PREMIUM TAX CREDITS INTO 22 HEALTHCARE AFFORDABILITY ACCOUNTS.—Section 23 1412 of the Patient Protection and Affordable Care Act 24 (42 U.S.C. 18082) is amended— 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 6 •S 3389 IS (1) in subsection (a)(3)— 1 (A) by striking ‘‘the Secretary of the 2 Treasury makes advance payments’’ and insert- 3 ing ‘‘the Secretary of the Treasury— 4 ‘‘(A) except as provided in subparagraph 5 (B), makes advance payments’’; 6 (B) by striking the period at the end and 7 inserting ‘‘, and’’; and 8 (C) by adding at the end the following new 9 subparagraph: 10 ‘‘(B) in the case of a plan year beginning 11 after December 31, 2026, and before January 12 1, 2032, makes advance payments— 13 ‘‘(i) of such premium tax credit into 14 the Healthcare Affordability Account main- 15 tained under section 223(i) of the Internal 16 Revenue Code of 1986 for each individual 17 eligible for such credit; and 18 ‘‘(ii) of such cost-sharing reductions 19 to the issuers of the qualified health plans 20 in order to reduce the premiums payable 21 by individuals eligible for such cost-sharing 22 reductions.’’; and 23 (2) in subsection (c)(2)— 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 7 •S 3389 IS (A) by striking ‘‘The Secretary’’ and in- 1 serting ‘‘Except as provided in subparagraph 2 (C), the Secretary’’; and 3 (B) by adding at the end the following new 4 subparagraph: 5 ‘‘(C) PAYMENT OF PREMIUM TAX CREDIT 6 INTO HEALTHCARE AFFORDABILITY AC- 7 COUNTS.—In the case of plan years beginning 8 after December 31, 2026, and before January 9 1, 2031, the Secretary of the Treasury shall 10 make the advance payment under this section 11 of any premium tax credit allowed under section 12 36B of the Internal Revenue Code of 1986 to 13 the Healthcare Affordability Account of the ap- 14 plicable individual on a monthly basis (or such 15 other periodic basis as the Secretary may pro- 16 vide).’’. 17 SEC. 104. HEALTHCARE AFFORDABILITY ACCOUNTS. 18 (a) IN GENERAL.—Section 223 of the Internal Rev- 19 enue Code of 1986 is amended by adding at the end the 20 following new subsection: 21 ‘‘(i) HEALTHCARE AFFORDABILITY ACCOUNTS.—For 22 purposes of this section— 23 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 8 •S 3389 IS ‘‘(1) IN GENERAL.—In the case of a Healthcare 1 Affordability Account, this section shall be applied 2 as provided in paragraphs (3) through (7). 3 ‘‘(2) HEALTHCARE AFFORDABILITY AC- 4 COUNT.—The term ‘Healthcare Affordability Ac- 5 count’ means a health savings account, determined 6 as provided in this subsection. 7 ‘‘(3) TREATMENT OF TRANSFERRED CONTRIBU- 8 TIONS.—Amounts transferred to a Healthcare Af- 9 fordability Account pursuant to section 1412 of the 10 Patient Protection and Affordable Care Act shall not 11 be taken into account in determining the deduction 12 allowed by subsection (a). 13 ‘‘(4) ACCOUNT MUST BE ONLY HSA OF INDI- 14 VIDUAL.— 15 ‘‘(A) IN GENERAL.—An individual who has 16 a Healthcare Affordability Account shall not be 17 treated as an eligible individual with respect to 18 any health savings account other than such 19 Healthcare Affordability Account. 20 ‘‘(B) ROLLOVER OF EXISTING ACCOUNT 21 PERMITTED.—An individual on whose behalf a 22 Healthcare Affordability Account is established 23 may roll over the balance of any other health 24 savings account of the individual to such 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 9 •S 3389 IS Healthcare Affordability Account according to 1 the rules of subsection (f)(5). 2 ‘‘(5) NO ROLLOVERS PERMITTED.—Except as 3 provided in paragraph (4)(B), subsection (f)(5) shall 4 not apply and no amount shall be contributed from 5 a Healthcare Affordability Account to any health 6 savings account other than a Healthcare Afford- 7 ability Account. 8 ‘‘(6) RESTRICTION ON USE OF AMOUNTS.—No 9 amounts in a Healthcare Affordability Account may 10 be used to pay for any— 11 ‘‘(A) gender transition procedures, or 12 ‘‘(B) abortion. 13 ‘‘(7) DEFINITIONS.—For purposes of paragraph 14 (6)— 15 ‘‘(A) GENDER TRANSITION PROCEDURE.— 16 ‘‘(i) IN GENERAL.—The term ‘gender 17 transition procedure’ means any hormonal 18 or surgical intervention for the purpose of 19 gender transition, including— 20 ‘‘(I) gonadotropin-releasing hor- 21 mone (GnRH) agonists or other pu- 22 berty-blocking or suppressing drugs to 23 stop or delay normal puberty; 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 10 •S 3389 IS ‘‘(II) testosterone, estrogen, pro- 1 gesterone, or other androgens to an 2 individual at doses that are 3 supraphysiologic to what would nor- 4 mally be produced endogenously in a 5 healthy individual of the same age 6 and sex; 7 ‘‘(III) castration; 8 ‘‘(IV) orchiectomy; 9 ‘‘(V) scrotoplasty; 10 ‘‘(VI) implantation of erection or 11 testicular prostheses; 12 ‘‘(VII) vasectomy; 13 ‘‘(VIII) hysterectomy; 14 ‘‘(IX) oophorectomy; 15 ‘‘(X) ovariectomy; 16 ‘‘(XI) reconstruction of the fixed 17 part of the urethra with or without a 18 metoidioplasty or a phalloplasty; 19 ‘‘(XII) metoidioplasty; 20 ‘‘(XIII) penectomy; 21 ‘‘(XIV) phalloplasty; 22 ‘‘(XV) vaginoplasty; 23 ‘‘(XVI) clitoroplasty; 24 ‘‘(XVII) vaginectomy; 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 11 •S 3389 IS ‘‘(XVIII) vulvoplasty; 1 ‘‘(XIX) reduction 2 thyrochondroplasty; 3 ‘‘(XX) chondrolaryngoplasty; 4 ‘‘(XXI) mastectomy; 5 ‘‘(XXII) tubal ligation; 6 ‘‘(XXIII) sterilization; 7 ‘‘(XXIV) any plastic, cosmetic, or 8 aesthetic surgery that feminizes or 9 masculinizes the facial or other phys- 10 iological features of an individual; 11 ‘‘(XXV) any placement of chest 12 implants to create feminine breasts; 13 ‘‘(XXVI) any placement of fat or 14 artificial implants in the gluteal re- 15 gion; 16 ‘‘(XXVII) augmentation 17 mammoplasty; 18 ‘‘(XXVIII) liposuction; 19 ‘‘(XXIX) lipofilling; 20 ‘‘(XXX) voice surgery; 21 ‘‘(XXXI) hair reconstruction; 22 ‘‘(XXXII) pectoral implants; and 23 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 12 •S 3389 IS ‘‘(XXXIII) the removal of any 1 otherwise healthy or non-diseased 2 body part or tissue. 3 ‘‘(ii) EXCLUSIONS.—The term ‘gender 4 transition procedure’ does not include the 5 following when furnished to an individual 6 by a health care provider with the consent 7 of such individual or, if applicable, such in- 8 dividual’s parents or legal guardian: 9 ‘‘(I) Services to individuals born 10 with a medically verifiable disorder of 11 sex development, including an indi- 12 vidual with external sex characteris- 13 tics that are irresolvably ambiguous, 14 such as an individual born with 46 15 XX chromosomes with virilization, an 16 individual born with 46 XY chro- 17 mosomes with undervirilization, or an 18 individual born having both ovarian 19 and testicular tissue. 20 ‘‘(II) Services provided when a 21 physician has otherwise diagnosed a 22 disorder of sexual development in 23 which the physician has determined 24 through genetic or biochemical testing 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 13 •S 3389 IS that the individual does not have nor- 1 mal sex chromosome structure, sex 2 steroid hormone production, or sex 3 steroid hormone action for a healthy 4 individual of the same sex and age. 5 ‘‘(III) The treatment of any in- 6 fection, injury, disease, or disorder 7 that has been caused by or exacer- 8 bated by the performance of gender 9 transition procedures, whether or not 10 the gender transition procedure was 11 performed in accordance with State 12 and Federal law or whether or not 13 funding for the gender transition pro- 14 cedure is permissible under this sec- 15 tion. 16 ‘‘(IV) Any procedure undertaken 17 because the individual suffers from a 18 physical disorder, physical injury, or 19 physical illness (but not mental, be- 20 havioral, or emotional distress or a 21 mental, behavioral, or emotional dis- 22 order) that would, as certified by a 23 physician, place the individual in im- 24 minent danger of death or impairment 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00013 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 14 •S 3389 IS of major bodily function, unless the 1 procedure is performed. 2 ‘‘(V) Puberty suppression or 3 blocking prescription drugs for the 4 purpose of normalizing puberty for a 5 minor experiencing precocious pu- 6 berty. 7 ‘‘(VI) Male circumcision. 8 ‘‘(B) GENDER TRANSITION.—The term 9 ‘gender transition’ means the process in which 10 an individual goes from identifying with or pre- 11 senting as his or her sex to identifying with or 12 presenting a self-proclaimed identity that does 13 not correspond with or is different from his or 14 her sex, and may be accompanied with social, 15 legal, or physical changes. 16 ‘‘(C) SEX.—The term ‘sex’, when referring 17 to an individual’s sex, means to refer to either 18 male or female, as biologically determined. 19 ‘‘(D) FEMALE.—The term ‘female’, when 20 used to refer to a natural person, means an in- 21 dividual who naturally has, had, will have, or 22 would have, but for a congenital anomaly, his- 23 torical accident, or intentional or unintentional 24 disruption, the reproductive system that at 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 15 •S 3389 IS some point produces, transports, and utilizes 1 eggs for fertilization. 2 ‘‘(E) MALE.—The term ‘male’, when used 3 to refer to a natural person, means an indi- 4 vidual who naturally has, had, will have, or 5 would have, but for a congenital anomaly, his- 6 torical accident, or intentional or unintentional 7 disruption, the reproductive system that at 8 some point produces, transports, and utilizes 9 sperm for fertilization. 10 ‘‘(F) ABORTION.— 11 ‘‘(i) IN GENERAL.—The term ‘abor- 12 tion’ means— 13 ‘‘(I) drugs or procedures used 14 with the primary intent to end the life 15 of the human being in the womb, 16 ‘‘(II) pre-viable delivery not de- 17 scribed in clause (ii), and 18 ‘‘(III) post-viable delivery with 19 intentional death of the fetus. 20 ‘‘(ii) EXCLUSIONS.—Such term does 21 not include— 22 ‘‘(I) separation of the mother 23 and her embryo or fetus to prevent 24 the mother’s death or immediate irre- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00015 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 16 •S 3389 IS versible bodily harm, which cannot be 1 mitigated in any other way, 2 ‘‘(II) treatment of ectopic or 3 molar pregnancy, 4 ‘‘(III) treatment of miscarriage, 5 or 6 ‘‘(IV) any service described in 7 clause (i) in the case of a pregnancy 8 which is the result of an act of rape 9 or incest.’’. 10 (b) EFFECTIVE DATE.—The amendment made by 11 this section shall apply to taxable years beginning after 12 December 31, 2026. 13 SEC. 105. EXTENSION OF TEMPORARY ENHANCED PRE- 14 MIUM CREDITS. 15 (a) IN GENERAL.—Clause (iii) of section 16 36B(b)(3)(A) of the Internal Revenue Code of 1986 is 17 amended— 18 (1) by striking ‘‘January 1, 2026’’ and insert- 19 ing ‘‘January 1, 2032’’, and 20 (2) by striking ‘‘2025’’ in the heading and in- 21 serting ‘‘2031’’. 22 (b) HOUSEHOLD INCOME LIMITATION.—Section 23 36B(c)(1)(E) of the Internal Revenue Code of 1986 is 24 amended— 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00016 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 17 •S 3389 IS (1) by striking ‘‘RULE FOR 2021 THROUGH 1 2025.—In the case of’’ and inserting the following: 2 ‘‘RULES FOR 2021 THROUGH 2031.— 3 ‘‘(i) IN GENERAL.—In the case of’’, 4 and 5 (2) by adding at the end the following new 6 clause: 7 ‘‘(ii) SPECIAL RULE FOR 2027 8 THROUGH 2031.—In the case of any tax- 9 able year beginning after December 31, 10 2026, and before January 1, 2032, sub- 11 paragraph (A) shall be applied by sub- 12 stituting ‘700 percent’ for ‘400 percent’.’’. 13 (c) PHASEDOWN OF ENHANCED AMOUNTS.—Sub- 14 paragraph (A) of section 36B(b)(3) of the Internal Rev- 15 enue Code of 1986 is amended by adding at the end the 16 following new clause: 17 ‘‘(iv) PHASEDOWN OF ENHANCED 18 AMOUNTS.— 19 ‘‘(I) IN GENERAL.—In the case 20 of a taxable year beginning after De- 21 cember 31, 2027, the premium assist- 22 ance amount determined under this 23 subsection (without regard to this 24 clause) shall be reduced by an amount 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00017 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 18 •S 3389 IS equal to the phasedown percentage of 1 the enhanced amount. 2 ‘‘(II) ENHANCED AMOUNT.—For 3 purposes of subclause (I), the term 4 ‘enhanced amount’ means the excess, 5 if any, of the premium assistance 6 amount determined under this sub- 7 section (without regard to this clause) 8 over the premium assistance amount 9 which would be so determined if 10 clause (iii) did not apply for the tax- 11 able year. 12 ‘‘(III) PHASEDOWN PERCENT- 13 AGE.—For purposes of subclause (I), 14 the phasedown percentage is— 15 ‘‘(aa) 20 percent, in the case 16 of a taxable year beginning after 17 December 31, 2027, and before 18 January 1, 2029, 19 ‘‘(bb) 40 percent, in the case 20 of a taxable year beginning after 21 December 31, 2028, and before 22 January 1, 2030, 23 ‘‘(cc) 60 percent, in the case 24 of a taxable year beginning after 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00018 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 19 •S 3389 IS December 31, 2029, and before 1 January 1, 2031, and 2 ‘‘(dd) 80 percent, in the case 3 of a taxable year beginning after 4 December 31, 2030, and before 5 January 1, 2032.’’. 6 (d) EFFECTIVE DATE.—The amendments made by 7 this section shall apply to taxable years beginning after 8 December 31, 2025. 9 SEC. 106. SPECIAL RULES RELATING TO COVERAGE OF 10 ABORTION SERVICES. 11 (a) IN GENERAL.—Section 1303(b) of the Patient 12 Protection and Affordable Care Act (42 U.S.C. 18023(b)) 13 is amended— 14 (1) in paragraph (2)— 15 (A) by amending subparagraph (A) to read 16 as follows: 17 ‘‘(A) PROHIBITION ON THE USE OF FED- 18 ERAL FUNDS.—If a qualified health plan pro- 19 vides coverage of services described in para- 20 graph (1)(B)(i), the issuer of the plan shall not 21 use any amount attributable to any cost-sharing 22 reduction under section 1402 of the Patient 23 Protection and Affordable Care Act (and the 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00019 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 20 •S 3389 IS amount (if any) of the advance payment of the 1 reduction under section 1412).’’; 2 (B) in subparagraph (B)(i)(I), by striking 3 ‘‘credits and cost-sharing reductions described 4 in subparagraph (A)’’ and inserting ‘‘cost-shar- 5 ing reductions described in subparagraph (A) 6 and premium tax credits under section 36B of 7 the Internal Revenue Code of 1986, and the 8 amount, if any, of the advance payment of such 9 credit under section 1412’’; and 10 (2) by amending paragraph (3) to read as fol- 11 lows: 12 ‘‘(3) RULES RELATING TO NOTICE.— 13 ‘‘(A) NOTICE.—A qualified health plan 14 that provides for coverage of the services de- 15 scribed in paragraph (1)(B)(i) shall, at the time 16 of enrollment, provide notice to enrollees— 17 ‘‘(i) that the plan includes such cov- 18 erage; 19 ‘‘(ii) the amount of the premium 20 charged for such coverage; and 21 ‘‘(iii) that such amount is not eligible 22 for the premium tax credit under section 23 36B of the Internal Revenue Code of 24 1986. 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00020 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 21 •S 3389 IS ‘‘(B) DISCLOSURES.— 1 ‘‘(i) IN GENERAL.—The issuer of a 2 plan described in subparagraph (A) shall 3 include the coverage of services described 4 in paragraph (1)(B)(i) as part of the sum- 5 mary of benefits and coverage explanation 6 for the plan, as applicable. 7 ‘‘(ii) COMPARATIVE INFORMATION.— 8 If one or more plans described in subpara- 9 graph (A) are offered through an Ex- 10 change in a State, the Exchange shall in- 11 clude in any standardized format for pre- 12 senting health benefits plan options to po- 13 tential enrollees, comparative information 14 on plan coverage of such services.’’. 15 (b) EFFECTIVE DATE.—The amendments made by 16 subsection (a) shall apply with respect to plan years begin- 17 ning after December 31, 2026. 18 SEC. 107. SPECIAL RULES RELATING TO CREDIT FOR 19 PLANS COVERING ABORTION SERVICES. 20 (a) IN GENERAL.—Paragraph (3) of section 36B(b) 21 of the Internal Revenue Code of 1986 is amended by add- 22 ing at the end the following new subparagraph: 23 ‘‘(F) SPECIAL RULE FOR ABORTION COV- 24 ERAGE.—If a qualified health plan offers cov- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00021 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 22 •S 3389 IS erage of abortion (as defined in section 1 223(i)(7)(F)), the portion of the premium for 2 the plan properly allocable (under rules pre- 3 scribed by the Secretary of Health and Human 4 Services) to such coverage shall not be taken 5 into account in determining either the monthly 6 premium or the adjusted monthly premium 7 under paragraph (2).’’. 8 (b) EFFECTIVE DATE.—The amendment made by 9 this section shall apply to taxable years beginning after 10 December 31, 2026. 11 SEC. 108. REPORTING OF HEALTH INSURANCE COVERAGE. 12 (a) IN GENERAL.—Subclause (II) of section 13 6055(b)(1)(B)(iii) of the Internal Revenue Code of 1986 14 is amended to read as follows: 15 ‘‘(II) in the case of a qualified 16 health plan— 17 ‘‘(aa) the amount of the 18 plan premium, 19 ‘‘(bb) if the plan provided 20 coverage of services described in 21 subsection (b)(1) of section 1303 22 of the Patient Protection and Af- 23 fordable Care Act, the amount of 24 the plan premium attributable to 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00022 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 23 •S 3389 IS such coverage (calculated as de- 1 scribed in subsection (b)(2)(B) of 2 such section), and 3 ‘‘(cc) the amount (if any) of 4 any advance payment under sec- 5 tion 1412 of the Patient Protec- 6 tion and Affordable Care Act of 7 any premium tax credit under 8 section 36B with respect to such 9 coverage, and’’. 10 (b) EFFECTIVE DATE.—The amendment made by 11 this section shall apply to taxable years beginning after 12 December 31, 2026. 13 SEC. 109. EXCLUSION OF GENDER TRANSITION PROCE- 14 DURES FROM COVERAGE UNDER QUALIFIED 15 HEALTH PLANS. 16 (a) IN GENERAL.—Section 1301(a)(1) of the Patient 17 Protection and Affordable Care Act (42 U.S.C. 18 18021(a)(1)) is amended— 19 (1) in subparagraph (B), by striking ‘‘and’’ 20 after the semicolon; 21 (2) in subparagraph (C)(iv), by striking the pe- 22 riod at the end and inserting ‘‘; and’’; and 23 (3) by adding at the end the following: 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00023 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 24 •S 3389 IS ‘‘(D) does not provide coverage for gender 1 transition procedures.’’. 2 (b) DEFINITION OF GENDER TRANSITION PROCE- 3 DURE.—Section 1301 of the Patient Protection and Af- 4 fordable Care Act (42 U.S.C. 18021) is amended by add- 5 ing at the end the following: 6 ‘‘(c) DEFINITIONS RELATING TO GENDER TRANSI- 7 TION PROCEDURES.— 8 ‘‘(1) GENDER TRANSITION PROCEDURE.— 9 ‘‘(A) IN GENERAL.—For purposes of sub- 10 section (a)(1)(D), the term ‘gender transition 11 procedure’ means any hormonal or surgical 12 intervention for the purpose of gender transi- 13 tion, including— 14 ‘‘(i) gonadotropin-releasing hormone 15 (GnRH) agonists or other puberty-blocking 16 or suppressing drugs to stop or delay nor- 17 mal puberty; 18 ‘‘(ii) testosterone, estrogen, progester- 19 one, or other androgens to an individual at 20 doses that are supraphysiologic to what 21 would normally be produced endogenously 22 in a healthy individual of the same age and 23 sex; 24 ‘‘(iii) castration; 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00024 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 25 •S 3389 IS ‘‘(iv) orchiectomy; 1 ‘‘(v) scrotoplasty; 2 ‘‘(vi) implantation of erection or tes- 3 ticular prostheses; 4 ‘‘(vii) vasectomy; 5 ‘‘(viii) hysterectomy; 6 ‘‘(ix) oophorectomy; 7 ‘‘(x) ovariectomy; 8 ‘‘(xi) reconstruction of the fixed part 9 of the urethra with or without a 10 metoidioplasty or a phalloplasty; 11 ‘‘(xii) metoidioplasty; 12 ‘‘(xiii) penectomy; 13 ‘‘(xiv) phalloplasty; 14 ‘‘(xv) vaginoplasty; 15 ‘‘(xvi) clitoroplasty; 16 ‘‘(xvii) vaginectomy; 17 ‘‘(xviii) vulvoplasty; 18 ‘‘(xix) reduction thyrochondroplasty; 19 ‘‘(xx) chondrolaryngoplasty; 20 ‘‘(xxi) mastectomy; 21 ‘‘(xxii) tubal ligation; 22 ‘‘(xxiii) sterilization; 23 ‘‘(xxiv) any plastic, cosmetic, or aes- 24 thetic surgery that feminizes or 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00025 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 26 •S 3389 IS masculinizes the facial or other physio- 1 logical features of an individual; 2 ‘‘(xxv) any placement of chest im- 3 plants to create feminine breasts; 4 ‘‘(xxvi) any placement of fat or artifi- 5 cial implants in the gluteal region; 6 ‘‘(xxvii) augmentation mammoplasty; 7 ‘‘(xxviii) liposuction; 8 ‘‘(xxix) lipofilling; 9 ‘‘(xxx) voice surgery; 10 ‘‘(xxxi) hair reconstruction; 11 ‘‘(xxxii) pectoral implants; and 12 ‘‘(xxxiii) the removal of any otherwise 13 healthy or non-diseased body part or tis- 14 sue. 15 ‘‘(B) EXCLUSIONS.—For purposes of sub- 16 section (a)(1)(D), the term ‘gender transition 17 procedure’ does not include the following when 18 furnished to an individual by a health care pro- 19 vider with the consent of such individual or, if 20 applicable, such individual’s parents or legal 21 guardian: 22 ‘‘(i) Services to individuals born with 23 a medically verifiable disorder of sex devel- 24 opment, including an individual with exter- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00026 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 27 •S 3389 IS nal sex characteristics that are irresolvably 1 ambiguous, such as an individual born with 2 46 XX chromosomes with virilization, an 3 individual born with 46 XY chromosomes 4 with undervirilization, or an individual 5 born having both ovarian and testicular 6 tissue. 7 ‘‘(ii) Services provided when a physi- 8 cian has otherwise diagnosed a disorder of 9 sexual development in which the physician 10 has determined through genetic or bio- 11 chemical testing that the individual does 12 not have normal sex chromosome struc- 13 ture, sex steroid hormone production, or 14 sex steroid hormone action for a healthy 15 individual of the same sex and age. 16 ‘‘(iii) The treatment of any infection, 17 injury, disease, or disorder that has been 18 caused by or exacerbated by the perform- 19 ance of gender transition procedures, 20 whether or not the gender transition proce- 21 dure was performed in accordance with 22 State and Federal law or whether or not 23 funding for the gender transition proce- 24 dure is permissible under this section. 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00027 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 28 •S 3389 IS ‘‘(iv) Any procedure undertaken be- 1 cause the individual suffers from a physical 2 disorder, physical injury, or physical illness 3 (but not mental, behavioral, or emotional 4 distress or a mental, behavioral, or emo- 5 tional disorder) that would, as certified by 6 a physician, place the individual in immi- 7 nent danger of death or impairment of 8 major bodily function, unless the procedure 9 is performed. 10 ‘‘(v) Puberty suppression or blocking 11 prescription drugs for the purpose of nor- 12 malizing puberty for a minor experiencing 13 precocious puberty. 14 ‘‘(vi) Male circumcision. 15 ‘‘(2) RELATED TERMS.—For purposes of para- 16 graph (1): 17 ‘‘(A) FEMALE.—The term ‘female’, when 18 used to refer to a natural person, means an in- 19 dividual who naturally has, had, will have, or 20 would have, but for a congenital anomaly, his- 21 torical accident, or intentional or unintentional 22 disruption, the reproductive system that at 23 some point produces, transports, and utilizes 24 eggs for fertilization. 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00028 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 29 •S 3389 IS ‘‘(B) GENDER TRANSITION.—The term 1 ‘gender transition’ means the process in which 2 an individual goes from identifying with or pre- 3 senting as his or her sex to identifying with or 4 presenting a self-proclaimed identity that does 5 not correspond with or is different from his or 6 her sex, and may be accompanied with social, 7 legal, or physical changes. 8 ‘‘(C) MALE.—The term ‘male’, when used 9 to refer to a natural person, means an indi- 10 vidual who naturally has, had, will have, or 11 would have, but for a congenital anomaly, his- 12 torical accident, or intentional or unintentional 13 disruption, the reproductive system that at 14 some point produces, transports, and utilizes 15 sperm for fertilization. 16 ‘‘(D) SEX.—The term ‘sex’, when referring 17 to an individual’s sex, means to refer to either 18 male or female, as biologically determined.’’. 19 (c) EFFECTIVE DATE.—The amendments made by 20 this section shall apply with respect to plan years begin- 21 ning on or after January 1, 2026. 22 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00029 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 30 •S 3389 IS SEC. 110. FUNDING COST SHARING REDUCTION PAYMENTS. 1 Section 1402 of the Patient Protection and Afford- 2 able Care Act (42 U.S.C. 18071) is amended by adding 3 at the end the following new subsection: 4 ‘‘(h) FUNDING.— 5 ‘‘(1) IN GENERAL.—There are appropriated out 6 of any monies in the Treasury not otherwise appro- 7 priated such sums as may be necessary for purposes 8 of making payments under this section for plan 9 years beginning on or after January 1, 2026. 10 ‘‘(2) LIMITATION.— 11 ‘‘(A) IN GENERAL.—The amounts appro- 12 priated under paragraph (1) may not be used 13 for purposes of making payments under this 14 section for a qualified health plan that provides 15 health benefit coverage that includes coverage 16 of abortion. 17 ‘‘(B) EXCEPTION.—Subparagraph (A) 18 shall not apply to payments for a qualified 19 health plan that provides coverage of abortion 20 only if necessary to save the life of the mother 21 or if the pregnancy is a result of an act of rape 22 or incest.’’. 23 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00030 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 31 •S 3389 IS SEC. 111. WAIVERS FOR STATE INNOVATION. 1 (a) STREAMLINING THE STATE APPLICATION PROC- 2 ESS.—Section 1332 of the Patient Protection and Afford- 3 able Care Act (42 U.S.C. 18052) is amended— 4 (1) in subsection (a)(1)(C), by striking ‘‘the 5 law’’ and inserting ‘‘a law or has in effect a certifi- 6 cation’’; and 7 (2) in subsection (b)(2)— 8 (A) in the paragraph heading, by inserting 9 ‘‘OR CERTIFY’’ after ‘‘LAW’’; 10 (B) in subparagraph (A)— 11 (i) by striking ‘‘A law’’ and inserting 12 the following: 13 ‘‘(i) LAWS.—A law’’; and 14 (ii) by adding at the end the fol- 15 lowing: 16 ‘‘(ii) CERTIFICATIONS.—A certifi- 17 cation described in this paragraph is a doc- 18 ument, signed by the Governor of the 19 State, that certifies that such Governor 20 has the authority under existing Federal 21 and State law to take action under this 22 section, including implementation of the 23 State plan under subsection (a)(1)(B).’’; 24 and 25 (C) in subparagraph (B)— 26 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00031 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 32 •S 3389 IS (i) in the subparagraph heading, by 1 striking ‘‘OF OPT OUT’’; and 2 (ii) by striking ‘‘may repeal a law’’ 3 and all that follows through the period at 4 the end and inserting the following: ‘‘may 5 terminate the authority provided under the 6 waiver with respect to the State by— 7 ‘‘(i) repealing a law described in sub- 8 paragraph (A)(i); or 9 ‘‘(ii) terminating a certification de- 10 scribed in subparagraph (A)(ii), through a 11 certification for such termination signed by 12 the Governor of the State.’’. 13 (b) GIVING STATES MORE FUNDING FLEXIBILITY, 14 TO ESTABLISH REINSURANCE, INVISIBLE HIGH-RISK 15 POOLS, INSURANCE STABILITY FUNDS, AND OTHER PRO- 16 GRAMS.— 17 (1) STATE GRANTS UNDER WAIVERS.—Section 18 1332(a) of the Patient Protection and Affordable 19 Care Act (42 U.S.C. 18052(a)) is amended— 20 (A) in paragraph (3)— 21 (i) in the first sentence— 22 (I) by inserting ‘‘or would qualify 23 for a reduced portion of’’ after ‘‘would 24 not qualify for’’; 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00032 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 33 •S 3389 IS (II) by inserting ‘‘, or the State 1 would not qualify for or would qualify 2 for a reduced portion of basic health 3 program funds under section 1331,’’ 4 after ‘‘subtitle E’’; 5 (III) by inserting ‘‘, or basic 6 health program funds the State would 7 have received,’’ after ‘‘this title’’; and 8 (IV) by inserting ‘‘or for imple- 9 menting the basic health program es- 10 tablished under section 1331’’ before 11 the period; 12 (ii) in the second sentence, by insert- 13 ing before the period ‘‘, and with respect to 14 participation in the basic health program 15 and funds provided to such other States 16 under section 1331’’; and 17 (iii) by adding after the second sen- 18 tence the following: ‘‘A State may request 19 that all of, or any portion of, such aggre- 20 gate amount of such credits, reductions, or 21 funds be paid to the State as described in 22 the first sentence.’’; 23 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00033 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 34 •S 3389 IS (B) by redesignating paragraphs (4), (5), 1 and (6) as paragraphs (5), (6), and (7), respec- 2 tively; and 3 (C) by inserting after paragraph (3) the 4 following: 5 ‘‘(4) FEDERAL FUNDING FOR INVISIBLE HIGH- 6 RISK POOL AND REINSURANCE PROGRAMS.— 7 ‘‘(A) ALLOCATIONS.—Not later than 45 8 days after the date of enactment of the Low- 9 ering Health Care Costs for Americans Act, the 10 Secretary, in consultation with the National As- 11 sociation of Insurance Commissioners, shall 12 specify an allocation methodology for deter- 13 mining the amount of funds appropriated under 14 section 2(a)(2)(B) of the Lowering Health Care 15 Costs for Americans Act for a fiscal year to be 16 allocated for each State for purposes of sub- 17 paragraph (B) and section 2(a)(2)(C) of the 18 Lowering Health Care Costs for Americans Act. 19 ‘‘(B) STATE GRANTS.—From amounts ap- 20 propriated under section 2(a)(2)(B) of the Low- 21 ering Health Care Costs for Americans Act for 22 a fiscal year, the Secretary shall award grants 23 to States for each of fiscal years 2027 through 24 2030, in amounts determined in accordance 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00034 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 35 •S 3389 IS with the allocation methodology under subpara- 1 graph (A), for the following purposes: 2 ‘‘(i) For fiscal year 2027, for adminis- 3 trative costs of the State associated with 4 preparing and submitting information de- 5 scribed in subsection (a)(1)(B) that in- 6 cludes an invisible high-risk pool or rein- 7 surance program that meets the require- 8 ments of subsection (g)(2), or costs associ- 9 ated with the establishment of such invis- 10 ible high-risk pool or reinsurance program. 11 ‘‘(ii) For each of fiscal years 2028, 12 2029, and 2030, for the establishment or 13 maintenance of invisible high-risk pools 14 and reinsurance programs that meet the 15 requirements of subsection (g)(2) and for 16 which the State has received a waiver 17 under this section. 18 ‘‘(C) BUDGET NEUTRALITY.—Funds 19 awarded to a State under a grant awarded 20 under subparagraph (B) shall not be taken into 21 account for purposes of determining under 22 paragraph (1) whether the State waiver is 23 budget neutral, or determining under subsection 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00035 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 36 •S 3389 IS (b)(1) whether the State waiver increases the 1 Federal deficit.’’. 2 (2) APPROPRIATIONS.— 3 (A) IN GENERAL.—There are authorized to 4 be appropriated, and there are appropriated, to 5 the Secretary of Health and Human Services, 6 for the purposes described in section 7 1332(a)(4)(B) of the Patient Protection and 8 Affordable Care Act and subparagraph (C), out 9 of any funds in the Treasury not otherwise ap- 10 propriated— 11 (i) $500,000,000 for fiscal year 2027; 12 and 13 (ii) $5,000,000,000 for each of fiscal 14 years 2028, 2029, and 2030. 15 (B) AVAILABLE UNTIL EXPENDED.— 16 Amounts appropriated under this paragraph 17 shall remain available until expended. 18 (3) DEFAULT FEDERAL SAFEGUARD.— 19 (A) IN GENERAL.—For purposes of plan 20 year 2026, in the case of a State that does not, 21 by a date specified by the Secretary of Health 22 and Human Services (referred to in this para- 23 graph as the ‘‘Secretary’’), in consultation with 24 the National Association of Insurance Commis- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00036 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 37 •S 3389 IS sioners, have in effect a waiver under section 1 1332 of the Patient Protection and Affordable 2 Care Act (42 U.S.C. 18052) that includes an 3 invisible high-risk pool or reinsurance program 4 that meets the requirements of subsection 5 (g)(2) of such section 1332, the Secretary shall, 6 from amounts appropriated under subpara- 7 graph (B), use the allocation determined for the 8 State under subsection (a)(4)(B) of such sec- 9 tion 1332 for plan year 2026 for the purpose 10 described in clause (ii) for such State. 11 (B) REQUIRED USE FOR MARKET STA- 12 BILIZATION PAYMENTS TO ISSUERS.—The Sec- 13 retary shall use any allocation for a State made 14 pursuant to clause (i) to provide incentives to 15 appropriate entities to enter into arrangements 16 with the State to help stabilize premiums for 17 health insurance coverage in the individual mar- 18 ket in such State by providing payments to 19 such appropriate entities using payment param- 20 eters and a methodology determined by the Sec- 21 retary. 22 (c) ENSURING PATIENT ACCESS TO MORE FLEXIBLE 23 HEALTH PLANS.—Section 1332 of the Patient Protection 24 and Affordable Care Act (42 U.S.C. 18052) is amended— 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00037 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 38 •S 3389 IS (1) in subsection (a)(1)(C), by striking ‘‘sub- 1 section (b)(2)’’ and inserting ‘‘subsection (b)(3)’’; 2 and 3 (2) in subsection (b)— 4 (A) in paragraph (1)— 5 (i) in subparagraph (B), by striking 6 ‘‘at least as affordable’’ and inserting ‘‘of 7 comparable affordability, including for low- 8 income individuals, individuals with serious 9 health needs, and other vulnerable popu- 10 lations,’’; and 11 (ii) by amending subparagraph (D) to 12 read as follows: 13 ‘‘(D)(i) will not increase the Federal deficit 14 over the term of the waiver; and 15 ‘‘(ii) will not increase the Federal deficit 16 over the term of the 10-year budget plan sub- 17 mitted under subsection (a)(1)(B)(ii).’’; 18 (B) by redesignating paragraph (2) (as 19 amended by paragraph (1)) as paragraph (3); 20 and 21 (C) by inserting after paragraph (1) the 22 following: 23 ‘‘(2) BUDGETARY EFFECT.— 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00038 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 39 •S 3389 IS ‘‘(A) IN GENERAL.—In determining wheth- 1 er a State plan submitted under subsection (a) 2 meets the deficit neutrality requirements of 3 paragraph (1)(D), the Secretary may take into 4 consideration the direct budgetary effect of the 5 provisions of such plan on sources of Federal 6 funding other than the funding described in 7 subsection (a)(3). 8 ‘‘(B) LIMITATION.—A determination made 9 by the Secretary under subparagraph (A)— 10 ‘‘(i) shall not be construed to affect 11 any waiver process or standards or terms 12 and conditions in effect on the date of en- 13 actment of the Lowering Health Care 14 Costs for Americans Act under title XI, 15 XVIII, XIX, or XXI of the Social Security 16 Act, or any other Federal law relating to 17 the provision of health care items or serv- 18 ices; and 19 ‘‘(ii) shall be made without regard to 20 any changes in policy with respect to any 21 waiver process or provision of health care 22 items or services described in clause (i).’’. 23 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00039 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 40 •S 3389 IS (d) PROVIDING EXPEDITED APPROVAL OF STATE 1 WAIVERS.—Section 1332(d) of the Patient Protection and 2 Affordable Care Act (42 U.S.C. 18052(d)) is amended— 3 (1) in paragraph (1) by striking ‘‘180’’ and in- 4 serting ‘‘120’’; and 5 (2) by adding at the end the following: 6 ‘‘(3) EXPEDITED DETERMINATION.— 7 ‘‘(A) IN GENERAL.—With respect to any 8 application under subsection (a)(1) submitted 9 on or after the date of enactment of the Low- 10 ering Health Care Costs for Americans Act or 11 any such application submitted prior to such 12 date of enactment and under review by the Sec- 13 retary on such date of enactment, the Secretary 14 shall make a determination on such application, 15 using the criteria for approval otherwise appli- 16 cable under this section, not later than 45 days 17 after the receipt of such application, and shall 18 allow the public notice and comment at the 19 State and Federal levels described under sub- 20 section (a)(5) to occur concurrently if such 21 State application— 22 ‘‘(i) is submitted in response to an ur- 23 gent situation, with respect to areas in the 24 State that the Secretary determines are at 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00040 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 41 •S 3389 IS risk for excessive premium increases or 1 having no health plans offered in the appli- 2 cable health insurance market for the cur- 3 rent or following plan year; 4 ‘‘(ii) is for a waiver that is the same 5 or substantially similar to a waiver that 6 the Secretary already has approved for an- 7 other State; or 8 ‘‘(iii) is for a waiver that includes an 9 invisible high-risk pool or reinsurance pro- 10 gram described in subparagraph (A), (B), 11 or (D) of subsection (g)(2). 12 ‘‘(B) APPROVAL.— 13 ‘‘(i) URGENT SITUATIONS.— 14 ‘‘(I) PROVISIONAL APPROVAL.—A 15 waiver approved under the expedited 16 determination process under subpara- 17 graph (A)(i) shall be in effect for a 18 period of 3 years, unless the State re- 19 quests a shorter duration. 20 ‘‘(II) FULL APPROVAL.—Subject 21 to the requirements for approval oth- 22 erwise applicable under this section, 23 not later than 1 year before the expi- 24 ration of a provisional waiver period 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00041 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 42 •S 3389 IS described in subclause (I) with respect 1 to an application described in sub- 2 paragraph (A)(i), the Secretary shall 3 make a determination on whether to 4 extend the approval of such waiver for 5 the full term of the waiver requested 6 by the State, for a total approval pe- 7 riod not to exceed 6 years. The Sec- 8 retary may request additional infor- 9 mation as the Secretary determines 10 appropriate to make such determina- 11 tion. 12 ‘‘(ii) APPROVAL OF SAME OR SIMILAR 13 APPLICATIONS.—An approval of a waiver 14 under subparagraph (A)(ii) shall be subject 15 to the terms of subsection (e). 16 ‘‘(C) GAO STUDY.—Not later than 5 years 17 after the date of enactment of the Lowering 18 Health Care Costs for Americans Act, the 19 Comptroller General of the United States shall 20 conduct a review of all waivers approved pursu- 21 ant to subparagraph (A)(ii) to evaluate whether 22 such waivers met the requirements of sub- 23 section (b)(1) and whether the applications 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00042 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 43 •S 3389 IS should have qualified for such expedited proc- 1 ess.’’. 2 (e) PROVIDING CERTAINTY FOR STATE-BASED RE- 3 FORMS.—Section 1332(e) of the Patient Protection and 4 Affordable Care Act (42 U.S.C. 18052(e)) is amended by 5 striking ‘‘No waiver’’ and all that follows through the pe- 6 riod at the end and inserting the following: ‘‘A waiver 7 under this section— 8 ‘‘(1) shall be in effect for a period of 6 years 9 unless the State requests a shorter duration; 10 ‘‘(2) may be renewed, subject to the State meet- 11 ing the criteria for approval otherwise applicable 12 under this section, for unlimited additional 6-year 13 periods upon application by the State; and 14 ‘‘(3) may not be suspended or terminated, in 15 whole or in part, by the Secretary at any time before 16 the date of expiration of the waiver period (including 17 any renewal period under paragraph (2)), unless the 18 Secretary determines that the State materially failed 19 to comply with the terms and conditions of the waiv- 20 er.’’. 21 (f) GUIDANCE AND REGULATIONS.—Section 1332 of 22 the Patient Protection and Affordable Care Act (42 23 U.S.C. 18052) is amended— 24 (1) by adding at the end the following: 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00043 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 44 •S 3389 IS ‘‘(f) GUIDANCE AND REGULATIONS.— 1 ‘‘(1) IN GENERAL.—With respect to carrying 2 out this section, the Secretary shall— 3 ‘‘(A) issue guidance, not later than 60 4 days after the date of enactment of the Low- 5 ering Health Care Costs for Americans Act, 6 that includes initial examples of model State 7 plans that meet the requirements for approval 8 under this section; and 9 ‘‘(B) periodically review the guidance 10 issued under subparagraph (A) and, when ap- 11 propriate, issue additional examples of model 12 State plans that meet the requirements for ap- 13 proval under this section, which may include— 14 ‘‘(i) State plans establishing reinsur- 15 ance or invisible high-risk pool arrange- 16 ments for purposes of covering the cost of 17 high-risk individuals; 18 ‘‘(ii) State plans expanding insurer 19 participation, access to affordable health 20 plans, network adequacy, and health plan 21 options over the entire applicable health in- 22 surance market in the State; 23 ‘‘(iii) waivers encouraging or requiring 24 health plans in such State to deploy value- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00044 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 45 •S 3389 IS based insurance designs which structure 1 enrollee cost-sharing and other health plan 2 design elements to encourage enrollees to 3 consume high-value clinical services; 4 ‘‘(iv) State plans allowing for signifi- 5 cant variation in health plan benefit de- 6 sign; or 7 ‘‘(v) any other State plan as the Sec- 8 retary determines appropriate. 9 ‘‘(2) RESCISSION OF PREVIOUS REGULATIONS 10 AND GUIDANCE.—Beginning on the date of enact- 11 ment of the Lowering Health Care Costs for Ameri- 12 cans Act, the regulations promulgated and the guid- 13 ance issued under this section prior to the date of 14 enactment of the Lowering Health Care Costs for 15 Americans Act shall have no force or effect.’’; and 16 (2) in subsection (a)(5) (as redesignated by 17 paragraph (2)(A)(ii))— 18 (A) in subparagraph (A), by inserting ‘‘, as 19 applicable’’ before the period; and 20 (B) in subparagraph (B), by striking ‘‘Not 21 later than 180 days after the date of enactment 22 of this Act, the Secretary shall’’ and inserting 23 ‘‘The Secretary may’’. 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00045 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 46 •S 3389 IS (g) INVISIBLE HIGH-RISK POOLS AND REINSURANCE 1 PROGRAMS.—Section 1332 of the Patient Protection and 2 Affordable Care Act (42 U.S.C. 18052), as amended by 3 paragraph (6), is further amended by adding at the end 4 the following: 5 ‘‘(g) INVISIBLE HIGH-RISK POOLS AND REINSUR- 6 ANCE PROGRAMS.— 7 ‘‘(1) FUNDING.—With respect to a State that 8 has received a waiver under this section to establish 9 an invisible high-risk pool or reinsurance program 10 described in paragraph (2), the State may fund such 11 program, in whole or in part, using one or both of 12 the following: 13 ‘‘(A) Amounts received through a grant de- 14 scribed in subsection (a)(4)(B). 15 ‘‘(B) All of, or a portion of, the payments 16 made to the State as described in subsection 17 (a)(3), consistent with the information the 18 State provides under subsection (a)(1)(B). 19 ‘‘(2) PROGRAM DESIGN.—An invisible high-risk 20 pool or reinsurance program described in this para- 21 graph is a program that meets any of the following: 22 ‘‘(A) An invisible high-risk pool, as defined 23 by the State, under which health insurance 24 issuers, with respect to designated individuals 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00046 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 47 •S 3389 IS who experience higher than average health costs 1 as determined by the State, and are enrolled in 2 health insurance coverage offered in the indi- 3 vidual market, cede risk to the pool, without af- 4 fecting the premium paid by the designated in- 5 dividuals or their terms of coverage. With re- 6 spect to such pool, the State, or an entity oper- 7 ating the pool on behalf of the State, shall es- 8 tablish— 9 ‘‘(i) the premium amount the ceding 10 issuer shall pay to the reinsurance pool; 11 ‘‘(ii) the applicable attachment points 12 or coinsurance percentages if the ceding 13 issuer retains any portion of the risk under 14 ceded policies; and 15 ‘‘(iii) the mechanism by which high- 16 risk individuals are designated for cession 17 to the pool, which may include a list of 18 designated high-cost health conditions. 19 ‘‘(B) A reinsurance program, as defined by 20 the State, that assumes a portion of the risk for 21 individuals who experience higher than average 22 health costs, as determined by the State, in a 23 manner substantially similar to the reinsurance 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00047 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 48 •S 3389 IS program that operated in the State in accord- 1 ance with section 1341. 2 ‘‘(C) A reinsurance program established by 3 the State not otherwise described in this para- 4 graph. 5 ‘‘(D) A program based on another State’s 6 reinsurance program— 7 ‘‘(i) described in subparagraph (A), 8 (B), or (C), for which an application has 9 been approved under this subsection; or 10 ‘‘(ii) which was implemented prior to 11 September 1, 2025, and which the Sec- 12 retary determines meets the requirements 13 of subparagraph (A).’’. 14 (h) APPLICABILITY.—The amendments made by this 15 Act to section 1332 of the Patient Protection and Afford- 16 able Care Act (42 U.S.C. 18052)— 17 (1) with respect to applications for waivers 18 under such section 1332 submitted after the date of 19 enactment of this Act and applications for such 20 waivers submitted prior to such date of enactment 21 and under review by the Secretary on the date of en- 22 actment, shall take effect on the date of enactment 23 of this Act; and 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00048 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 49 •S 3389 IS (2) with respect to applications for waivers ap- 1 proved under such section 1332 before the date of 2 enactment of this Act, shall not require reconsider- 3 ation of whether such applications meet the require- 4 ments of such section 1332, except that, at the re- 5 quest of a State, the Secretary shall recalculate the 6 amount of funding provided under subsection (a)(3) 7 of such section. 8 (i) CLARIFYING BUDGET NEUTRALITY.—Section 9 1332(a)(1)(B) of the Patient Protection and Affordable 10 Care Act (42 U.S.C. 18052(a)(1)(B)) is amended— 11 (1) in clause (i), by inserting ‘‘, including, as 12 applicable, a description of the State’s plan to use 13 any amounts awarded to the State under paragraph 14 (4) to support an invisible high-risk pool or reinsur- 15 ance program consistent with subsection (g) and 16 such information about such program as the Sec- 17 retary may require’’ before the semicolon; and 18 (2) in clause (ii), by inserting ‘‘over both the 19 term of the proposed waiver and the term of the 10- 20 year budget plan’’ after ‘‘Government’’. 21 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00049 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 50 •S 3389 IS TITLE II—HOSPITAL TRANS- 1 PARENCY REQUIREMENTS 2 SEC. 201. STRENGTHENING HOSPITAL PRICE TRANS- 3 PARENCY REQUIREMENTS. 4 (a) IN GENERAL.—Section 2718(e) of the Public 5 Health Service Act (42 U.S.C. 300gg–18(e)) is amended 6 to read as follows: 7 ‘‘(e) STANDARD HOSPITAL CHARGES.— 8 ‘‘(1) IN GENERAL.— 9 ‘‘(A) DISCLOSURE OF STANDARD 10 CHARGES.—Each hospital shall, in accordance 11 with a method and format established by the 12 Secretary under subparagraph (C), on a month- 13 ly basis compile and make public (without sub- 14 scription and free of charge)— 15 ‘‘(i) all of the hospital’s standard 16 charges (including the information de- 17 scribed in subparagraph (B)) for each item 18 and service furnished by such hospital; and 19 ‘‘(ii) hospital standard charge infor- 20 mation, including the information de- 21 scribed in subparagraph (B), in a con- 22 sumer-friendly format (as specified by the 23 Secretary), that includes— 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00050 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 51 •S 3389 IS ‘‘(I) as many of the Centers for 1 Medicare & Medicaid Services-speci- 2 fied shoppable services that are fur- 3 nished by the hospital, and as many 4 additional hospital-selected shoppable 5 services (or all such additional serv- 6 ices, if such hospital furnishes fewer 7 than 300 shoppable services) as may 8 be necessary for a combined total of 9 at least 300 shoppable services 10 through December 31, 2026, after 11 which the hospital’s prices shall in- 12 clude all shoppable services; and 13 ‘‘(II) with respect to each Cen- 14 ters for Medicare & Medicaid Serv- 15 ices-specified shoppable service that is 16 not furnished by the hospital, an indi- 17 cation that such service is not so fur- 18 nished. 19 ‘‘(B) STANDARD CHARGES DESCRIBED.— 20 For purposes of subparagraph (A), standard 21 charges means: 22 ‘‘(i) A plain language description of 23 each item or service, accompanied by any 24 applicable billing codes, including modi- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00051 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 52 •S 3389 IS fiers, using commonly recognized billing 1 code sets, including the Current Proce- 2 dural Terminology code, the Healthcare 3 Common Procedure Coding System code, 4 the diagnosis-related group, the National 5 Drug Code, and other nationally recog- 6 nized identifier. 7 ‘‘(ii) The gross charge, expressed as a 8 dollar amount, for each such item or serv- 9 ice, when provided in, as applicable, the in- 10 patient setting and outpatient department 11 setting. 12 ‘‘(iii) The discounted cash price ex- 13 pressed as a dollar amount, for each such 14 item or service when provided in, as appli- 15 cable, the inpatient setting and outpatient 16 department setting (or, in the case no dis- 17 counted cash price is available for an item 18 or service, the minimum cash price accept- 19 ed by the hospital from self-pay individuals 20 for such item or service, expressed as a 21 dollar amount, as well as, with respect to 22 prices made public pursuant to subpara- 23 graph (A)(ii), a link to a consumer-friendly 24 document that clearly explains the hos- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00052 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 53 •S 3389 IS pital’s charity care policy). The hospital 1 shall accept the discounted cash price as 2 payment in full from any patient that 3 chooses to pay in cash without regard to 4 the patient’s coverage. 5 ‘‘(iv) The payer-specific negotiated 6 charges, expressed as a dollar amount and 7 clearly associated with the name of the ap- 8 plicable third party payer and name of 9 each plan, that apply to each such item or 10 service when provided in, as applicable, the 11 inpatient setting and outpatient depart- 12 ment setting. If the charges are based on 13 an algorithm, percentage of another 14 amount, or other formula or criteria, the 15 hospital also shall disclose such algorithm, 16 percentage, formula, or criteria as set forth 17 in its contract and any other terms, sched- 18 ules, exhibits, data, or other information 19 referenced in any such contract as shall be 20 required to determine and disclose the ne- 21 gotiated charge. 22 ‘‘(v) The de-identified maximum and 23 minimum negotiated charges for each such 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00053 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 54 •S 3389 IS item or service, expressed as a non-zero 1 dollar amount. 2 ‘‘(vi) Any other additional information 3 the Secretary may require for the purpose 4 of improving the accuracy of, or enabling 5 consumers to easily understand and com- 6 pare, standard charges and prices for an 7 item or service, except information that is 8 duplicative of any other reporting require- 9 ment under this subsection. In the case of 10 standard charges and prices for an item or 11 service included as part of a bundled, per 12 diem, episodic, or other similar arrange- 13 ment, the information described in this 14 subparagraph shall be made available as 15 determined appropriate by the Secretary. 16 ‘‘(C) UNIFORM METHOD AND FORMAT.— 17 Not later than January 1, 2026, the Secretary 18 shall establish a standard, uniform method and 19 format for hospitals to use in compiling and 20 making public standard charges pursuant to 21 subparagraph (A)(i) and a standard, uniform 22 method and format for such hospitals to use in 23 compiling and making public prices pursuant to 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00054 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 55 •S 3389 IS subparagraph (A)(ii). Such methods and for- 1 mats shall— 2 ‘‘(i) in the case of such method and 3 format for making public standard charges 4 pursuant to subparagraph (A)(i), ensure 5 that such charges are made available in a 6 machine-readable spreadsheet format; 7 ‘‘(ii) meet such standards as deter- 8 mined appropriate by the Secretary in 9 order to ensure the accessibility and 10 usability of such charges and prices; and 11 ‘‘(iii) be updated as determined appro- 12 priate by the Secretary, in consultation 13 with stakeholders. 14 ‘‘(2) NO DEEMED COMPLIANCE.—The avail- 15 ability of a price estimator tool shall not be consid- 16 ered to deem compliance with or otherwise vitiate 17 the requirements of paragraph (1)(A)(ii) or any 18 other requirements of this section. Furthermore, the 19 use of an estimator tool shall not be used for pur- 20 poses of compliance with any provisions in this Sec- 21 tion. 22 ‘‘(3) MONITORING COMPLIANCE.—The Sec- 23 retary shall, in consultation with the Inspector Gen- 24 eral of the Department of Health and Human Serv- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00055 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 56 •S 3389 IS ices, establish a process to monitor compliance with 1 this subsection. Such process shall ensure that each 2 hospital’s compliance with this subsection is re- 3 viewed not less frequently than once every year. 4 ‘‘(4) ATTESTATION.—A senior official from 5 each hospital (the Chief Executive Officer, Chief Fi- 6 nancial Officer, or an official of equivalent seniority) 7 shall attest to the accuracy and completeness of the 8 disclosures made in accordance with the hospital 9 price transparency requirements set forth in this 10 regulation. Such attestation shall be deemed to be 11 material to payment from the Federal Government 12 to the hospital. 13 ‘‘(5) ENFORCEMENT.— 14 ‘‘(A) IN GENERAL.—In the case of a hos- 15 pital that fails to comply with the requirements 16 of this subsection, not later than 30 days after 17 the date on which the Secretary determines 18 such failure exists, the Secretary shall submit 19 to such hospital a notification of such deter- 20 mination, which shall include a request for a 21 corrective action plan to comply with such re- 22 quirements. 23 ‘‘(B) CIVIL MONETARY PENALTY.— 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00056 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 57 •S 3389 IS ‘‘(i) IN GENERAL.—In addition to any 1 other enforcement actions or penalties that 2 may apply under another provision of law, 3 a hospital that has received a request for 4 a corrective action plan under subpara- 5 graph (A) and fails to comply with the re- 6 quirements of this subsection by the date 7 that is 45 days after such request is made 8 shall be subject to a civil monetary penalty 9 of an amount specified by the Secretary for 10 each day (beginning with the day on which 11 the Secretary first determined that such 12 hospital was not complying with such re- 13 quirements) during which such failure was 14 ongoing. Such amount shall not exceed— 15 ‘‘(I) in the case of a hospital with 16 30 or fewer beds, $300 per day; 17 ‘‘(II) in the case of a hospital 18 with more than 30 beds but fewer 19 than 101 beds, $12.50 per bed per 20 day (or, in the case of such a hospital 21 that has been noncompliant with such 22 requirements for a 1-year period or 23 longer, beginning with the first day 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00057 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 58 •S 3389 IS following such 1-year period, $15 per 1 bed per day); 2 ‘‘(III) in the case of a hospital 3 with more than 100 beds but fewer 4 than 301 beds, $17.50 per bed per 5 day (or, in the case of such a hospital 6 that has been noncompliant with such 7 requirements for a 1-year period or 8 longer, beginning with the first day 9 following such 1-year period, $20 per 10 bed per day); 11 ‘‘(IV) in the case of a hospital 12 with more than 300 beds but fewer 13 than 501 beds, $20 per bed per day 14 (or, in the case of such a hospital that 15 has been noncompliant with such re- 16 quirements for a 1-year period or 17 longer, beginning with the first day 18 following such 1-year period, $25 per 19 bed per day); and 20 ‘‘(V) in the case of a hospital 21 with more than 500 beds, $25 per bed 22 per day (or, in the case of such a hos- 23 pital that has been noncompliant with 24 such requirements for a 1-year period 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00058 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 59 •S 3389 IS or longer, beginning with the first day 1 following such 1-year period, $35 per 2 bed per day). 3 ‘‘(ii) INCREASE AUTHORITY.—In ap- 4 plying this subparagraph with respect to 5 violations occurring in 2027 or a subse- 6 quent year, the Secretary may through no- 7 tice and comment rulemaking increase— 8 ‘‘(I) the limitation on the per day 9 amount of any penalty applicable to a 10 hospital under clause (i)(I); 11 ‘‘(II) the limitations on the per 12 bed per day amount of any penalty 13 applicable under any of subclauses 14 (II) through (V) of clause (i); and 15 ‘‘(III) the limitation on the in- 16 crease of any penalty applied under 17 clause (iii) pursuant to the amounts 18 specified in subclause (II) of such 19 clause. 20 ‘‘(iii) PERSISTENT NONCOMPLI- 21 ANCE.— 22 ‘‘(I) IN GENERAL.—In the case 23 of a hospital that the Secretary has 24 determined to be knowingly and will- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00059 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 60 •S 3389 IS fully noncompliant with the provisions 1 of this subsection two or more times 2 during a 1-year period, the Secretary 3 may increase any penalty otherwise 4 applicable under this subparagraph by 5 the amount specified in subclause (II) 6 with respect to such hospital and may 7 require such hospital to complete such 8 additional corrective actions plans as 9 the Secretary may specify. 10 ‘‘(II) SPECIFIED AMOUNT.—For 11 purposes of subclause (I), the amount 12 specified in this subclause is, with re- 13 spect to a hospital— 14 ‘‘(aa) with more than 30 15 beds but fewer than 101 beds, an 16 amount that is not less than 17 $500,000 and not more than 18 $1,000,000; 19 ‘‘(bb) with more than 100 20 beds but fewer than 301 beds, an 21 amount that is greater than 22 $1,000,000 and not more than 23 $2,000,000; 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00060 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 61 •S 3389 IS ‘‘(cc) with more than 300 1 beds but fewer than 501 beds, an 2 amount that is greater than 3 $2,000,000 and not more than 4 $4,000,000; and 5 ‘‘(dd) with more than 500 6 beds, and amount that is not less 7 than $5,000,000 and not more 8 than $10,000,000. 9 ‘‘(iv) PROVISION OF TECHNICAL AS- 10 SISTANCE.—The Secretary may, to the ex- 11 tent practicable, provide technical assist- 12 ance relating to compliance with the provi- 13 sions of this section to hospitals requesting 14 such assistance. 15 ‘‘(v) APPLICATION OF CERTAIN PROVI- 16 SIONS.—The provisions of section 1128A 17 (other than subsections (a) and (b) of such 18 section) shall apply to a civil monetary 19 penalty imposed under this subparagraph 20 in the same manner as such provisions 21 apply to a civil monetary penalty imposed 22 under subsection (a) of such section. 23 ‘‘(C) NO WAIVER.—The Secretary shall not 24 grant or extend any waiver, delay, tolling, or 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00061 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 62 •S 3389 IS other mitigation of a civil monetary penalty for 1 violation of this subsection. 2 ‘‘(6) DEFINITIONS.—For purposes of this sub- 3 section: 4 ‘‘(A) DISCOUNTED CASH PRICE.—The 5 term ‘discounted cash price’ means the min- 6 imum charge, exclusive of any hospital or third- 7 party payer assistance, that the hospital accepts 8 from an individual who pays cash, or cash 9 equivalent, for a hospital-furnished item or 10 service, without regard to patient coverage, as 11 payment in full. 12 ‘‘(B) GROSS CHARGE.—The term ‘gross 13 charge’ means the charge for an individual item 14 or service that is reflected on a hospital’s 15 chargemaster, absent any discounts. 16 ‘‘(C) HOSPITAL.—The term ‘hospital’ 17 means a hospital (as defined in section 1861(e) 18 of the Social Security Act), a critical access 19 hospital (as defined in section 1861(mmm)(1) 20 of the Social Security Act), or a rural emer- 21 gency hospital (as defined in section 1861(kkk) 22 of the Social Security Act), together with any 23 parent, subsidiary, or other affiliated provider 24 or supplier of health care items and services 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00062 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 63 •S 3389 IS without regard to whether such parent, sub- 1 sidiary, or other affiliated provider or supplier 2 operates under separate licensure, certification, 3 or designation. 4 ‘‘(D) PAYER-SPECIFIC NEGOTIATED 5 CHARGE.—The term ‘payer-specific negotiated 6 charge’ means the charge that a hospital has 7 negotiated with a third party payer for an item 8 or service. 9 ‘‘(E) SHOPPABLE SERVICE.—The term 10 ‘shoppable service’ means a service that can be 11 scheduled by a health care consumer in advance 12 and includes all ancillary items and services 13 customarily furnished as part of such service. 14 ‘‘(F) THIRD PARTY PAYER.—The term 15 ‘third party payer’ means an entity that is, by 16 statute, contract, or agreement, legally respon- 17 sible for payment of a claim for a health care 18 item or service. 19 ‘‘(7) RULEMAKING.—The Secretary shall imple- 20 ment this subsection through notice and comment 21 rulemaking in accordance with section 553 of title 5, 22 United States Code.’’. 23 (b) EFFECTIVE DATE.— 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00063 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 64 •S 3389 IS (1) IN GENERAL.—The amendment made by 1 subsection (a) shall apply beginning January 1, 2 2026. 3 (2) CONTINUED APPLICABILITY OF RULES FOR 4 PREVIOUS YEARS.—Nothing in the amendment made 5 by this section may be construed as affecting the ap- 6 plicability of the regulations codified at part 180 of 7 title 45, Code of Federal Regulations, before Janu- 8 ary 1, 2026. 9 (c) CONTINUED APPLICABILITY OF STATE LAW.— 10 The provisions of this title shall not supersede any provi- 11 sion of State law that establishes, implements, or con- 12 tinues in effect any requirement or prohibition related to 13 health care price transparency, except to the extent that 14 such requirement or prohibition prevents the application 15 of a requirement or prohibition of this title. 16 SEC. 202. INCREASING PRICE TRANSPARENCY OF CLINICAL 17 DIAGNOSTIC LABORATORY TESTS. 18 Section 2718 of the Public Health Service Act (42 19 U.S.C. 300gg–18) is amended by adding at the end the 20 following: 21 ‘‘(f) CLINICAL DIAGNOSTIC LABORATORY PRICE 22 TRANSPARENCY.— 23 ‘‘(1) IN GENERAL.—Beginning July 1, 2027, an 24 applicable laboratory shall— 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00064 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 65 •S 3389 IS ‘‘(A) make publicly available on an internet 1 website the information described in paragraph 2 (2) with respect to each such specified clinical 3 diagnostic laboratory test that such laboratory 4 so furnishes; and 5 ‘‘(B) ensure that such information is up- 6 dated not less frequently than monthly, if there 7 have been any changes to such information. 8 ‘‘(2) INFORMATION DESCRIBED.—For purposes 9 of paragraph (1), the information described in this 10 paragraph is, with respect to an applicable labora- 11 tory and a specified clinical diagnostic laboratory 12 test, the following: 13 ‘‘(A) A plain language description of each 14 item or service, accompanied by any applicable 15 billing codes, including modifiers, using com- 16 monly recognized billing code sets, including the 17 Current Procedural Terminology code, the 18 Healthcare Common Procedure Coding System 19 code, the diagnosis-related group, the National 20 Drug Code, and other nationally recognized 21 identifier. 22 ‘‘(B) The gross charge expressed as a dol- 23 lar amount, for each such item or service. 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00065 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 66 •S 3389 IS ‘‘(C) The discounted cash price expressed 1 as a dollar amount, for each such item or serv- 2 ice (or, in the case no discounted cash price is 3 available for an item or service, the minimum 4 cash price accepted by the laboratory from self- 5 pay individuals for such item or service when 6 provided in such settings for the previous three 7 years, expressed as a dollar amount, as well as, 8 with respect to prices made public pursuant to 9 subparagraph (A)(ii), a link to a consumer- 10 friendly document that clearly explains the lab- 11 oratory’s charity care policy). The laboratory 12 shall accept the discounted or minimum cash 13 price as payment in full from any patient that 14 chooses to pay in cash without regard to the pa- 15 tient’s coverage. 16 ‘‘(D) The payer-specific negotiated 17 charges, expressed as a dollar amount and 18 clearly associated with the name of the applica- 19 ble third party payer and name of each plan, 20 that apply to each such item or service when 21 provided in, as applicable, the inpatient setting 22 and outpatient department setting. If the 23 charges are based on an algorithm, percentage 24 of another amount, or other formula or criteria, 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00066 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 67 •S 3389 IS the clinical diagnostic laboratory also shall dis- 1 close such algorithm, percentage, formula, or 2 criteria as set forth in its contract and any 3 other terms, schedules, exhibits, data, or other 4 information referenced in any such contract as 5 shall be required to determine and disclose the 6 negotiated charge. 7 ‘‘(E) The de-identified maximum and min- 8 imum negotiated charges for each such item or 9 service, expressed as a non-zero dollar amount. 10 ‘‘(F) Any other additional information the 11 Secretary may require for the purpose of im- 12 proving the accuracy of, or enabling consumers 13 to easily understand and compare, standard 14 charges and prices for an item or service, ex- 15 cept information that is duplicative of any other 16 reporting requirement under this subsection. In 17 the case of standard charges and prices for an 18 item or service included as part of a bundled, 19 per diem, episodic, or other similar arrange- 20 ment, the information described in this sub- 21 paragraph shall be made available as deter- 22 mined appropriate by the Secretary. 23 ‘‘(3) UNIFORM METHOD AND FORMAT.—Not 24 later than January 1, 2027, the Secretary shall es- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00067 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 68 •S 3389 IS tablish a standard, uniform method and format for 1 applicable laboratories to use in compiling and mak- 2 ing public information pursuant to paragraph (1). 3 Such method and format shall— 4 ‘‘(A) include a machine-readable spread- 5 sheet format containing the information de- 6 scribed in paragraph (2) for all items and serv- 7 ices furnished by each laboratory; 8 ‘‘(B) meet such standards as determined 9 appropriate by the Secretary in order to ensure 10 the accessibility and usability of such informa- 11 tion; and 12 ‘‘(C) be updated as determined appropriate 13 by the Secretary, in consultation with stake- 14 holders. 15 ‘‘(4) INCLUSION OF ANCILLARY SERVICES.— 16 Any price or rate for a specified clinical diagnostic 17 laboratory test available to be furnished by an appli- 18 cable laboratory made publicly available in accord- 19 ance with paragraph (1) shall include the price or 20 rate for any ancillary item or service (including spec- 21 imen collection services, specimen transport, cen- 22 trifugation, aliquoting, labeling, requisition proc- 23 essing, and standard result reporting services) that 24 would customarily and routinely be furnished by 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00068 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 69 •S 3389 IS such laboratory as part of such test, as specified by 1 the Secretary. 2 ‘‘(5) ENFORCEMENT.— 3 ‘‘(A) IN GENERAL.—In the case that the 4 Secretary determines that an applicable labora- 5 tory is not in compliance with paragraph (1)— 6 ‘‘(i) not later than 30 days after such 7 determination, the Secretary shall notify 8 such laboratory of such determination; and 9 ‘‘(ii) if such laboratory continues to 10 fail to comply with such paragraph after 11 the date that is 90 days after such notifi- 12 cation is sent, the Secretary may impose a 13 civil monetary penalty in an amount not to 14 exceed $300 for each day (beginning with 15 the day on which the Secretary first deter- 16 mined that such laboratory was failing to 17 comply with such paragraph) during which 18 such failure is ongoing. 19 ‘‘(B) INCREASE AUTHORITY.—In applying 20 this paragraph with respect to violations occur- 21 ring in 2028 or a subsequent year, the Sec- 22 retary may through notice and comment rule- 23 making increase the per day limitation on civil 24 monetary penalties under subparagraph (A)(ii). 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00069 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 70 •S 3389 IS ‘‘(C) APPLICATION OF CERTAIN PROVI- 1 SIONS.—The provisions of section 1128A of the 2 Social Security Act (other than subsections (a) 3 and (b) of such section) shall apply to a civil 4 monetary penalty imposed under this paragraph 5 in the same manner as such provisions apply to 6 a civil monetary penalty imposed under sub- 7 section (a) of such section. 8 ‘‘(6) PROVISION OF TECHNICAL ASSISTANCE.— 9 The Secretary shall, to the extent practicable, pro- 10 vide technical assistance relating to compliance with 11 the provisions of this subsection to applicable labora- 12 tories requesting such assistance. 13 ‘‘(7) DEFINITIONS.—In this subsection: 14 ‘‘(A) APPLICABLE LABORATORY.—The 15 term ‘applicable laboratory’ means a ‘labora- 16 tory’ as such term is defined in section 493.2, 17 of title 42, Code of Federal Regulations (or a 18 successor regulation), except that such term 19 does not include a laboratory with respect to 20 which standard charges and prices for specified 21 clinical diagnostic laboratory tests furnished by 22 such laboratory are made available by a hos- 23 pital pursuant to subsection (e) of this section. 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00070 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 71 •S 3389 IS ‘‘(B) DISCOUNTED CASH PRICE.—The 1 term ‘discounted cash price’ means the charge 2 that applies to an individual who pays cash, or 3 cash equivalent, for an item or service. 4 ‘‘(C) GROSS CHARGE.—The term ‘gross 5 charge’ means the charge for an individual item 6 or service that is reflected on an applicable lab- 7 oratory’s chargemaster, absent any discounts. 8 ‘‘(D) PAYER-SPECIFIC NEGOTIATED 9 CHARGE.—The term ‘payer-specific negotiated 10 charge’ means the charge that an applicable 11 laboratory has negotiated with a third party 12 payer for an item or service. 13 ‘‘(E) SPECIFIED CLINICAL DIAGNOSTIC 14 LABORATORY TEST.—The term ‘specified clin- 15 ical diagnostic laboratory test’ means a clinical 16 diagnostic laboratory test that is included on 17 the list of shoppable services specified by the 18 Centers for Medicare & Medicaid Services (as 19 described in subsection (e) of this section), 20 other than such a test that is only available to 21 be furnished by a single provider of services or 22 supplier. 23 ‘‘(F) THIRD PARTY PAYER.—The term 24 ‘third party payer’ means an entity that is, by 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00071 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 72 •S 3389 IS statute, contract, or agreement, legally respon- 1 sible for payment of a claim for a health care 2 item or service. 3 ‘‘(8) RULEMAKING.—The Secretary shall imple- 4 ment this subsection through notice and comment 5 rulemaking in accordance with section 553 of title 5, 6 United States Code.’’. 7 SEC. 203. IMAGING TRANSPARENCY. 8 Section 2718 of the Public Health Service Act (42 9 U.S.C. 300gg–18), as amended by section 202, is further 10 amended by adding at the end the following: 11 ‘‘(g) IMAGING SERVICES PRICE TRANSPARENCY.— 12 ‘‘(1) IN GENERAL.—Beginning July 1, 2027, 13 each provider of services or supplier that furnishes 14 a specified imaging service, other than such a pro- 15 vider or supplier with respect to which standard 16 charges and prices for such services furnished by 17 such provider or supplier are made available by a 18 hospital pursuant to subsection (e), shall— 19 ‘‘(A) make publicly available (in accord- 20 ance with paragraph (3)) on an internet website 21 the information described in paragraph (2) with 22 respect to each such service that such provider 23 of services or supplier furnishes; and 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00072 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 73 •S 3389 IS ‘‘(B) ensure that such information is up- 1 dated not less frequently than annually. 2 ‘‘(2) INFORMATION DESCRIBED.—For purposes 3 of paragraph (1), the information described in this 4 paragraph is, with respect to a provider of services 5 or supplier and a specified imaging service, the fol- 6 lowing: 7 ‘‘(A) A plain language description of each 8 item or service, accompanied by any applicable 9 billing codes, including modifiers, using com- 10 monly recognized billing code sets, including the 11 Current Procedural Terminology code, the 12 Healthcare Common Procedure Coding System 13 code, the diagnosis-related group, the National 14 Drug Code, and other nationally recognized 15 identifier. 16 ‘‘(B) The gross charge expressed as a dol- 17 lar amount, for each such item or service. 18 ‘‘(C) The discounted cash price expressed 19 as a dollar amount, for each such item or serv- 20 ice (or, in the case no discounted cash price is 21 available for an item or service, the minimum 22 cash price accepted by the provider of services 23 or supplier from self-pay individuals for such 24 item or service when provided in such settings 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00073 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 74 •S 3389 IS for the previous three years, expressed as a dol- 1 lar amount, as well as, with respect to prices 2 made public pursuant to subparagraph (A)(ii), 3 a link to a consumer-friendly document that 4 clearly explains the provider of services or sup- 5 plier’s charity care policy). The provider of 6 services or supplier shall accept the discounted 7 or minimum cash price as payment in full from 8 any patient that chooses to pay in cash without 9 regard to the patient’s coverage. 10 ‘‘(D) The payer-specific negotiated 11 charges, expressed as a dollar amount and 12 clearly associated with the name of the applica- 13 ble third party payer and name of each plan, 14 that apply to each such item or service when 15 provided in, as applicable, the inpatient setting 16 and outpatient department setting. If the 17 charges are based on an algorithm, percentage 18 of another amount, or other formula or criteria, 19 the provider or supplier also shall disclose such 20 algorithm, percentage, formula, or criteria as 21 set forth in its contract and any other terms, 22 schedules, exhibits, data, or other information 23 referenced in any such contract as shall be re- 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00074 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 75 •S 3389 IS quired to determine and disclose the negotiated 1 charge. 2 ‘‘(E) The de-identified maximum and min- 3 imum negotiated charges for each such item or 4 service, expressed as a non-zero dollar amount. 5 ‘‘(F) Any other additional information the 6 Secretary may require for the purpose of im- 7 proving the accuracy of, or enabling consumers 8 to easily understand and compare, standard 9 charges and prices for an item or service, ex- 10 cept information that is duplicative of any other 11 reporting requirement under this subsection. In 12 the case of standard charges and prices for an 13 item or service included as part of a bundled, 14 per diem, episodic, or other similar arrange- 15 ment, the information described in this sub- 16 paragraph shall be made available as deter- 17 mined appropriate by the Secretary. 18 ‘‘(3) UNIFORM METHOD AND FORMAT.—Not 19 later than January 1, 2027, the Secretary shall es- 20 tablish a standard, uniform method and format for 21 providers of services and suppliers to use in making 22 public information described in paragraph (2). Any 23 such method and format shall— 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00075 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 76 •S 3389 IS ‘‘(A) include a machine-readable spread- 1 sheet format containing the information de- 2 scribed in paragraph (2) for all items and serv- 3 ices furnished by each provider of services and 4 supplier described in paragraph (1); 5 ‘‘(B) meet such standards as determined 6 appropriate by the Secretary in order to ensure 7 the accessibility and usability of such informa- 8 tion; and 9 ‘‘(C) be updated as determined appropriate 10 by the Secretary, in consultation with stake- 11 holders. 12 ‘‘(4) MONITORING COMPLIANCE.—The Sec- 13 retary shall, through notice and comment rule- 14 making and in consultation with the Inspector Gen- 15 eral of the Department of Health and Human Serv- 16 ices, establish a process to monitor compliance with 17 this subsection. 18 ‘‘(5) ENFORCEMENT.— 19 ‘‘(A) IN GENERAL.—In the case that the 20 Secretary determines that a provider of services 21 or supplier is not in compliance with paragraph 22 (1)— 23 ‘‘(i) not later than 30 days after such 24 determination, the Secretary shall notify 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00076 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 77 •S 3389 IS such provider or supplier of such deter- 1 mination; 2 ‘‘(ii) upon request of the Secretary, 3 such provider or supplier shall submit to 4 the Secretary, not later than 45 days after 5 the date of such request, a corrective ac- 6 tion plan to comply with such paragraph; 7 and 8 ‘‘(iii) if such provider or supplier con- 9 tinues to fail to comply with such para- 10 graph after the date that is 90 days after 11 such notification is sent (or, in the case of 12 such a provider or supplier that has sub- 13 mitted a corrective action plan described in 14 clause (ii) in response to a request so de- 15 scribed, after the date that is 90 days after 16 such submission), the Secretary may im- 17 pose a civil monetary penalty in an amount 18 not to exceed $300 for each day (beginning 19 with the day on which the Secretary first 20 determined that such provider or supplier 21 was failing to comply with such paragraph) 22 during which such failure to comply or fail- 23 ure to submit is ongoing. 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00077 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 78 •S 3389 IS ‘‘(B) INCREASE AUTHORITY.—In applying 1 this paragraph with respect to violations occur- 2 ring in 2027 or a subsequent year, the Sec- 3 retary may through notice and comment rule- 4 making increase the amount of the civil mone- 5 tary penalty under subparagraph (A)(iii). 6 ‘‘(C) APPLICATION OF CERTAIN PROVI- 7 SIONS.—The provisions of section 1128A of the 8 Social Security Act (other than subsections (a) 9 and (b) of such section) shall apply to a civil 10 monetary penalty imposed under this paragraph 11 in the same manner as such provisions apply to 12 a civil monetary penalty imposed under sub- 13 section (a) of such section. 14 ‘‘(D) NO AUTHORITY TO WAIVE OR RE- 15 DUCE PENALTY.—The Secretary shall not grant 16 or extend any waiver, delay, tolling, or other 17 mitigation of a civil monetary penalty for viola- 18 tion of this subsection. 19 ‘‘(E) PROVISION OF TECHNICAL ASSIST- 20 ANCE.—The Secretary shall, to the extent prac- 21 ticable, provide technical assistance relating to 22 compliance with the provisions of this sub- 23 section to providers of services and suppliers re- 24 questing such assistance. 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00078 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 79 •S 3389 IS ‘‘(F) CLARIFICATION OF NONAPPLICA- 1 BILITY OF OTHER ENFORCEMENT PROVI- 2 SIONS.—Notwithstanding any other provision of 3 this title, this paragraph shall be the sole 4 means of enforcing the provisions of this sub- 5 section. 6 ‘‘(6) SPECIFIED IMAGING SERVICE DEFINED.— 7 The term ‘specified imaging service’ means an imag- 8 ing service that is a Centers for Medicare & Med- 9 icaid Services-specified shoppable service (as de- 10 scribed in subsection (e)). 11 ‘‘(7) RULEMAKING.—The Secretary shall imple- 12 ment this subsection through notice and comment 13 rulemaking in accordance with section 553 of title 5, 14 United States Code.’’. 15 SEC. 204. AMBULATORY SURGICAL CENTER PRICE TRANS- 16 PARENCY REQUIREMENTS. 17 Section 2718 of the Public Health Service Act (42 18 U.S.C. 300gg–18), as amended by section 203, is further 19 amended by adding at the end the following: 20 ‘‘(h) AMBULATORY SURGERY CENTER TRANS- 21 PARENCY.— 22 ‘‘(1) IN GENERAL.—Beginning July 1, 2027, 23 each specified ambulatory surgical center shall com- 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00079 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 80 •S 3389 IS ply with the price transparency requirement de- 1 scribed in paragraph (2). 2 ‘‘(2) REQUIREMENT DESCRIBED.— 3 ‘‘(A) IN GENERAL.—A specified ambula- 4 tory surgical center, in accordance with a meth- 5 od and format established by the Secretary 6 under subparagraph (C), shall compile and 7 make public (without subscription and free of 8 charge), for each year— 9 ‘‘(i) one or more lists, in a machine- 10 readable format specified by the Secretary, 11 of the ambulatory surgical center’s stand- 12 ard charges (including the information de- 13 scribed in subparagraph (B)) for each item 14 and service furnished by such surgical cen- 15 ter; 16 ‘‘(ii) information in a consumer- 17 friendly format (as specified by the Sec- 18 retary) on the ambulatory surgical center’s 19 prices (including the information described 20 in subparagraph (B)) for as many of the 21 Centers for Medicare & Medicaid Services- 22 specified shoppable services included on the 23 list described in subsection (e) that are 24 furnished by such surgical center, and as 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00080 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 81 •S 3389 IS many additional ambulatory surgical cen- 1 ter-selected shoppable services (or all such 2 additional services, if such surgical center 3 furnishes fewer than 300 shoppable serv- 4 ices) as may be necessary for a combined 5 total of at least 300 shoppable services; 6 and 7 ‘‘(iii) with respect to each Centers for 8 Medicare & Medicaid Services-specified 9 shoppable service (as described in clause 10 (ii)) that is not furnished by the ambula- 11 tory surgical center, an indication that 12 such service is not so furnished. 13 ‘‘(B) INFORMATION DESCRIBED.—For pur- 14 poses of subparagraph (A), the information de- 15 scribed in this subparagraph is, with respect to 16 standard charges and prices made public by a 17 specified ambulatory surgical center, the fol- 18 lowing: 19 ‘‘(i) A description of each item or 20 service, accompanied by the Healthcare 21 Common Procedure Coding System code, 22 the national drug code, or other identifier 23 used or approved by the Centers for Medi- 24 care & Medicaid Services. 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00081 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 82 •S 3389 IS ‘‘(ii) The gross charge, expressed as a 1 dollar amount, for each such item or serv- 2 ice. 3 ‘‘(iii) The discounted cash price, ex- 4 pressed as a dollar amount, for each such 5 item or service (or, in the case no dis- 6 counted cash price is available for an item 7 or service, the minimum cash price accept- 8 ed by the specified ambulatory surgical 9 center from self-pay individuals for such 10 item or service when provided in such set- 11 tings for the previous three years, ex- 12 pressed as a dollar amount, as well as, 13 with respect to prices made public pursu- 14 ant to subparagraph (A)(ii), a link to a 15 consumer-friendly document that clearly 16 explains the provider of services or sup- 17 plier’s charity care policy). The specified 18 ambulatory surgical center shall accept the 19 discounted cash price as payment in full 20 from any patient that chooses to pay in 21 cash without regard to the patient’s cov- 22 erage. 23 ‘‘(iv) The payer-specific negotiated 24 charges, expressed as a dollar amount and 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00082 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 83 •S 3389 IS clearly associated with the name of the ap- 1 plicable third party payer and name of 2 each plan, that apply to each such item or 3 service when provided in, as applicable, the 4 inpatient setting and outpatient depart- 5 ment setting. If the charges are based on 6 an algorithm, percentage of another 7 amount, or other formula or criteria, the 8 ambulatory surgical center also shall dis- 9 close such algorithm, percentage, formula, 10 or criteria as set forth in its contract and 11 any other terms, schedules, exhibits, data, 12 or other information referenced in any 13 such contract as shall be required to deter- 14 mine and disclose the negotiated charge. 15 ‘‘(v) The de-identified maximum and 16 minimum negotiated charges for each such 17 item or service, expressed as a non-zero 18 dollar amount. 19 ‘‘(vi) Any other additional information 20 the Secretary may require for the purpose 21 of improving the accuracy of, or enabling 22 consumers to easily understand and com- 23 pare, standard charges and prices for an 24 item or service, except information that is 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00083 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 84 •S 3389 IS duplicative of any other reporting require- 1 ment under this subsection. 2 ‘‘(C) UNIFORM METHOD AND FORMAT.— 3 Not later than January 1, 2027, the Secretary 4 shall establish a standard, uniform method and 5 format for specified ambulatory surgical centers 6 to use in making public standard charges pur- 7 suant to subparagraph (A)(i) and a standard, 8 uniform method and format for such centers to 9 use in making public prices pursuant to sub- 10 paragraph (A)(ii). Any such method and format 11 shall— 12 ‘‘(i) in the case of such charges made 13 public by an ambulatory surgical center, 14 ensure that such charges are made avail- 15 able in a machine-readable format; 16 ‘‘(ii) meet such standards as deter- 17 mined appropriate by the Secretary in 18 order to ensure the accessibility and 19 usability of such charges and prices; and 20 ‘‘(iii) be updated as determined appro- 21 priate by the Secretary, in consultation 22 with stakeholders. 23 ‘‘(3) NO DEEMED COMPLIANCE.—The avail- 24 ability of a price estimator tool shall not be consid- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00084 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 85 •S 3389 IS ered to deem compliance with or otherwise vitiate 1 the requirements of this subsection (aa). Further- 2 more, the use of an estimator tool shall not be used 3 for purposes of compliance with any provisions in 4 this subsection. 5 ‘‘(4) MONITORING COMPLIANCE.—The Sec- 6 retary shall, in consultation with the Inspector Gen- 7 eral of the Department of Health and Human Serv- 8 ices, establish a process to monitor compliance with 9 this subsection. Such process shall ensure that each 10 specified ambulatory surgical center’s compliance 11 with this subsection is reviewed not less frequently 12 than once every year. 13 ‘‘(5) ENFORCEMENT.— 14 ‘‘(A) IN GENERAL.—In the case of a speci- 15 fied ambulatory surgical center that fails to 16 comply with the requirements of this sub- 17 section— 18 ‘‘(i) the Secretary shall notify such 19 ambulatory surgical center of such failure 20 not later than 30 days after the date on 21 which the Secretary determines such fail- 22 ure exists; and 23 ‘‘(ii) upon request of the Secretary, 24 the ambulatory surgical center shall submit 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00085 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 86 •S 3389 IS to the Secretary, not later than 45 days 1 after the date of such request, a corrective 2 action plan to comply with such require- 3 ments. 4 ‘‘(B) CIVIL MONETARY PENALTY.— 5 ‘‘(i) IN GENERAL.—A specified ambu- 6 latory surgical center that has received a 7 notification under subparagraph (A)(i) and 8 fails to comply with the requirements of 9 this subsection by the date that is 90 days 10 after such notification (or, in the case of 11 an ambulatory surgical center that has 12 submitted a corrective action plan de- 13 scribed in subparagraph (A)(ii) in response 14 to a request so described, by the date that 15 is 90 days after such submission) shall be 16 subject to a civil monetary penalty of an 17 amount specified by the Secretary for each 18 day (beginning with the day on which the 19 Secretary first determined that such hos- 20 pital was not complying with such require- 21 ments) during which such failure is ongo- 22 ing (not to exceed $300 per day). 23 ‘‘(ii) INCREASE AUTHORITY.—In ap- 24 plying this subparagraph with respect to 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00086 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 87 •S 3389 IS violations occurring in 2027 or a subse- 1 quent year, the Secretary may through no- 2 tice and comment rulemaking increase the 3 limitation on the per day amount of any 4 penalty applicable to a specified ambula- 5 tory surgical center under clause (i). 6 ‘‘(iii) APPLICATION OF CERTAIN PRO- 7 VISIONS.—The provisions of section 1128A 8 of the Social Security Act (other than sub- 9 sections (a) and (b) of such section) shall 10 apply to a civil monetary penalty imposed 11 under this subparagraph in the same man- 12 ner as such provisions apply to a civil mon- 13 etary penalty imposed under subsection (a) 14 of such section. 15 ‘‘(iv) NO AUTHORITY TO WAIVE OR 16 REDUCE PENALTY.—The Secretary shall 17 not grant or extend any waiver, delay, toll- 18 ing, or other mitigation of a civil monetary 19 penalty for violation of this subsection. 20 ‘‘(6) PROVISION OF TECHNICAL ASSISTANCE.— 21 The Secretary shall, to the extent practicable, pro- 22 vide technical assistance relating to compliance with 23 the provisions of this subsection to specified ambula- 24 tory surgical centers requesting such assistance. 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00087 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 88 •S 3389 IS ‘‘(7) DEFINITIONS.—For purposes of this sec- 1 tion: 2 ‘‘(A) DISCOUNTED CASH PRICE.—The 3 term ‘discounted cash price’ means the charge 4 that applies to an individual who pays cash, or 5 cash equivalent, for a item or service furnished 6 by an ambulatory surgical center. 7 ‘‘(B) GROSS CHARGE.—The term ‘gross 8 charge’ means the charge for an individual item 9 or service that is reflected on a specified sur- 10 gical center’s chargemaster, absent any dis- 11 counts. 12 ‘‘(C) GROUP HEALTH PLAN; GROUP 13 HEALTH INSURANCE COVERAGE; INDIVIDUAL 14 HEALTH INSURANCE COVERAGE.—The terms 15 ‘group health plan’, ‘group health insurance 16 coverage’, and ‘individual health insurance cov- 17 erage’ have the meaning given such terms in 18 section 2791 of the Public Health Service Act. 19 ‘‘(D) PAYER-SPECIFIC NEGOTIATED 20 CHARGE.—The term ‘payer-specific negotiated 21 charge’ means the charge that a specified sur- 22 gical center has negotiated with a third party 23 payer for an item or service. 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00088 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 89 •S 3389 IS ‘‘(E) SHOPPABLE SERVICE.—The term 1 ‘shoppable service’ means a service that can be 2 scheduled by a health care consumer in advance 3 and includes all ancillary items and services 4 customarily furnished as part of such service. 5 ‘‘(F) SPECIFIED AMBULATORY SURGICAL 6 CENTER.—The term ‘specified ambulatory sur- 7 gical center’ means an ambulatory surgical cen- 8 ter with respect to which a hospital (or any per- 9 son with an ownership or control interest (as 10 defined in section 1124(a)(3) of the Social Se- 11 curity Act) in a hospital) is a person with an 12 ownership or control interest (as so defined). 13 ‘‘(G) THIRD PARTY PAYER.—The term 14 ‘third party payer’ means an entity that is, by 15 statute, contract, or agreement, legally respon- 16 sible for payment of a claim for a health care 17 item or service. 18 ‘‘(8) RULEMAKING.—The Secretary shall imple- 19 ment this subsection through notice and comment 20 rulemaking in accordance with section 553 of title 5, 21 United States Code.’’. 22 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00089 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 90 •S 3389 IS SEC. 205. STRENGTHENING HEALTH COVERAGE TRANS- 1 PARENCY REQUIREMENTS. 2 (a) TRANSPARENCY IN COVERAGE.—Section 3 1311(e)(3)(C) of the Patient Protection and Affordable 4 Care Act (42 U.S.C. 18031(e)(3)(C)) is amended— 5 (1) by striking ‘‘The Exchange’’ and inserting 6 the following: 7 ‘‘(i) IN GENERAL.—The Exchange’’; 8 (2) in clause (i), as inserted by paragraph (1)— 9 (A) by striking ‘‘participating provider’’ 10 and inserting ‘‘provider’’; 11 (B) by inserting ‘‘shall include the infor- 12 mation specified in clause (ii) and’’ after ‘‘such 13 information’’; 14 (C) by striking ‘‘an Internet website’’ and 15 inserting ‘‘a self-service tool that meets the re- 16 quirements of clause (iii)’’; and 17 (D) by striking ‘‘and such other’’ and all 18 that follows through the period and inserting 19 ‘‘or, at the option such individual, through a 20 paper or phone disclosure (as selected by such 21 individual and provided at no cost to such indi- 22 vidual) that meets such requirements as the 23 Secretary may specify.’’; and 24 (3) by adding at the end the following new 25 clauses: 26 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00090 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 91 •S 3389 IS ‘‘(ii) SPECIFIED INFORMATION.—For 1 purposes of clause (i), the information 2 specified in this clause is, with respect to 3 benefits available under a health plan for 4 an item or service furnished by a health 5 care provider, the following: 6 ‘‘(I) If such provider is a partici- 7 pating provider with respect to such 8 item or service, the in-network rate 9 (as defined in subparagraph (F)) for 10 such item or service. 11 ‘‘(II) If such provider is not de- 12 scribed in subclause (I), the maximum 13 allowed dollar amount for such item 14 or service. 15 ‘‘(III) The amount of cost shar- 16 ing (including deductibles, copay- 17 ments, and coinsurance) that the indi- 18 vidual will incur for such item or serv- 19 ice (which, in the case such item or 20 service is to be furnished by a pro- 21 vider described in subclause (II), shall 22 be calculated using the maximum 23 amount described in such subclause). 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00091 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 92 •S 3389 IS ‘‘(IV) The amount the individual 1 has already accumulated with respect 2 to any deductible or out of pocket 3 maximum under the plan (broken 4 down, in the case separate deductibles 5 or maximums apply to separate indi- 6 viduals enrolled in the plan, by such 7 separate deductibles or maximums, in 8 addition to any cumulative deductible 9 or maximum). 10 ‘‘(V) In the case such plan im- 11 poses any frequency or volume limita- 12 tions with respect to such item or 13 service (excluding medical necessity 14 determinations), the amount that such 15 individual has accrued towards such 16 limitation with respect to such item or 17 service. 18 ‘‘(VI) Any prior authorization, 19 concurrent review, step therapy, fail 20 first, or similar requirements applica- 21 ble to coverage of such item or service 22 under such plan. 23 ‘‘(iii) SELF-SERVICE TOOL.—For pur- 24 poses of clause (i), a self-service tool estab- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00092 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 93 •S 3389 IS lished by a health plan meets the require- 1 ments of this clause if such tool— 2 ‘‘(I) is based on an internet 3 website; 4 ‘‘(II) provides for real-time re- 5 sponses to requests described in such 6 clause; 7 ‘‘(III) is updated in a manner 8 such that information provided 9 through such tool is timely and accu- 10 rate; 11 ‘‘(IV) allows such a request to be 12 made with respect to an item or serv- 13 ice furnished by— 14 ‘‘(aa) a specific provider 15 that is a participating provider 16 with respect to such item or serv- 17 ice; 18 ‘‘(bb) all providers that are 19 participating providers with re- 20 spect to such plan and such item 21 or service; or 22 ‘‘(cc) a provider that is not 23 described in item (bb); 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00093 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 94 •S 3389 IS ‘‘(V) provides that such a request 1 may be made with respect to an item 2 or service through use of— 3 ‘‘(aa) the billing code for 4 such item or service; or 5 ‘‘(bb) through use of a de- 6 scriptive term for such item or 7 service to produce a list of billing 8 code options from which the indi- 9 vidual selects to indicate the sub- 10 ject matter items or services; and 11 ‘‘(VI) holds a member harmless 12 for the amount of any difference in 13 excess of the amount of the individ- 14 ual’s responsibility generated by the 15 self-service tool and the amount ulti- 16 mately billed or charged to the indi- 17 vidual.’’. 18 (b) DISCLOSURE OF ADDITIONAL INFORMATION.— 19 Section 1311(e)(3) of the Patient Protection and Afford- 20 able Care Act (42 U.S.C. 18031(e)(3)) is amended by add- 21 ing at the end the following new subparagraphs: 22 ‘‘(E) RATE AND PAYMENT INFORMA- 23 TION.— 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00094 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 95 •S 3389 IS ‘‘(i) IN GENERAL.—Not later than 1 January 1, 2027, and every month there- 2 after, each health plan shall submit to the 3 Exchange, the Secretary, the State insur- 4 ance commissioner, and make available to 5 the public, the rate and payment informa- 6 tion described in clause (ii) in accordance 7 with clause (iii). 8 ‘‘(ii) RATE AND PAYMENT INFORMA- 9 TION DESCRIBED.—For purposes of clause 10 (i), the rate and payment information de- 11 scribed in this clause is, with respect to a 12 health plan, the following: 13 ‘‘(I) With respect to each item or 14 service for which benefits are available 15 under such plan (expressed as a dollar 16 amount), including prescription drugs, 17 identified by CPT, HCPCS, DRG, 18 NDC, or other applicable nationally 19 recognized identifier, including any 20 applicable code modifiers, and accom- 21 panied by a brief description of the 22 item or service, the in-network rate in 23 effect as of the date of the submission 24 of such information with each pro- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00095 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 96 •S 3389 IS vider (identified by national provider 1 identifier) that is a participating pro- 2 vider with respect to such item or 3 service, other than such a rate in ef- 4 fect with a provider— 5 ‘‘(aa) that has submitted no 6 claims; and 7 ‘‘(bb) expects to receive no 8 claims in the then applicable cal- 9 endar year for such item or serv- 10 ice to such plan. 11 ‘‘(II) With respect to each drug 12 (identified by National Drug Code, J- 13 code, or other commonly recognized 14 billing code used for drugs) for which 15 benefits are available under such plan: 16 ‘‘(aa) The in-network rate 17 (expressed as a dollar amount), 18 including the individual and total 19 amounts for any bundled rates, 20 in effect as of the first day of the 21 month in which such information 22 is made public with each provider 23 that is a participating provider 24 with respect to such drug. 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00096 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 97 •S 3389 IS ‘‘(bb) The historical net 1 price paid by such plan (net of 2 rebates, discounts, and price con- 3 cessions) (expressed as a dollar 4 amount) for such drug dispensed 5 or administered during the 90- 6 day period beginning 180 days 7 before such date of submission to 8 each provider that was a partici- 9 pating provider with respect to 10 such drug, broken down by each 11 such provider (identified by na- 12 tional provider identifier), other 13 than such an amount paid to a 14 provider that has submitted no 15 claims for such drug to such 16 plan. 17 ‘‘(III) With respect to each item 18 or service for which benefits are avail- 19 able under such plan (expressed as a 20 dollar amount), identified by CPT, 21 DRG, HCPCS, NDC, or other appli- 22 cable nationally recognized identifier, 23 including any applicable code modi- 24 fiers, and accompanied by a brief de- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00097 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 98 •S 3389 IS scription of the item or service, the 1 amount billed or charged by the pro- 2 vider, and the amount allowed by the 3 plan, for each such item or service 4 furnished during the 90-day period 5 beginning 180 days before such date 6 of submission by each provider that 7 was not a participating provider with 8 respect to such item or service, broken 9 down by each such provider (identified 10 by national provider identifier), other 11 than items and services with respect 12 to which no claims for such item or 13 service were submitted to such plan 14 during such period. 15 ‘‘(iii) MANNER OF SUBMISSION.—Rate 16 and payment information required to be 17 submitted and made available under this 18 subparagraph shall be so submitted and so 19 made available as follows: 20 ‘‘(I) Information shall be con- 21 tained in 3 separate machine-readable 22 files corresponding to the information 23 described in each of subclauses (I) 24 through (III) of clause (ii) that meet 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00098 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 99 •S 3389 IS such requirements as specified by the 1 Secretary through rulemaking, in con- 2 sultation with the Secretaries of 3 Labor and the Treasury to apply com- 4 parable requirements to group health 5 plans and to entities providing benefit 6 management or other third-party ad- 7 ministration services on a contractual 8 basis with a group health plan. 9 ‘‘(II) Requirements specified by 10 the Secretary through rulemaking 11 shall ensure that: 12 ‘‘(aa) Such files are limited 13 to an appropriate size, are made 14 available in a widely available 15 format that allows for informa- 16 tion contained in such files to be 17 compared across health plans, 18 and are accessible to individuals 19 at no cost and without the need 20 to establish a user account or 21 provider other credentials. 22 ‘‘(bb) The rates, amounts, 23 and prices to be disclosed include 24 contractual terms containing cal- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00099 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 100 •S 3389 IS culation formulae, pricing meth- 1 odologies, and other information 2 necessary to determine the dollar 3 value of reimbursement. 4 ‘‘(cc) Each such file includes 5 each of the following data ele- 6 ments: 7 ‘‘(AA) A numerical 8 identifier for the group 9 health plan and/or health in- 10 surance issuer (such as a 11 Health Insurance Oversight 12 System identifier). 13 ‘‘(BB) A plain-language 14 description of the item or 15 service (including, for drugs, 16 the proprietary and non- 17 proprietary name assigned). 18 ‘‘(CC) The billing code, 19 including any applicable 20 modifiers, associated with 21 such item or service, includ- 22 ing the Healthcare Common 23 Procedure Coding System 24 code, diagnosis-related 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00100 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 101 •S 3389 IS group, national drug code, 1 or other commonly recog- 2 nized code set. 3 ‘‘(DD) The place of 4 service code. 5 ‘‘(EE) The National 6 Provider Identifier or pro- 7 vider Tax Identification 8 Number. 9 ‘‘(III) The rate and payment in- 10 formation disclosed under subclauses 11 (I) through (III) of clause (ii) shall be 12 separately delineated for each item or 13 service, regardless of whether such 14 item or service is reimbursed as a part 15 of a bundle, episode, or other group- 16 ing of items and services. 17 ‘‘(IV) An officer or executive of 18 competent authority shall attest to the 19 accuracy and completeness of infor- 20 mation submitted and made available 21 under this subparagraph. Such attes- 22 tation shall be subject to enforcement 23 under subparagraph (H) and, where 24 applicable, shall be deemed material 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00101 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 102 •S 3389 IS to payments from the Federal Govern- 1 ment received by the group health 2 plan or health insurance issuer. 3 ‘‘(V) Regulations promulgated 4 pursuant to this section shall provide 5 that: 6 ‘‘(aa) The Secretary shall 7 audit the three machine-readable 8 files required by subparagraph 9 (E)(ii) posted by no fewer than 10 20 group health plans or health 11 insurance issuers. 12 ‘‘(bb) The Secretary of 13 Labor shall audit the three ma- 14 chine-readable files required by 15 subparagraph (E)(ii) posted by 16 no fewer than 200 group health 17 plans or service providers fur- 18 nishing third-party administrator 19 services to a group health plan. 20 ‘‘(cc) Findings, conclusions, 21 and enforcement actions taken 22 based on audits of the machine- 23 readable files shall be reported 24 annually to Congress no later 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00102 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 103 •S 3389 IS than July 1 of the calendar year 1 during which the files were au- 2 dited. Such report to Congress 3 shall be accessible to the public. 4 ‘‘(iv) USER GUIDE.—Each health plan 5 shall make available to the public instruc- 6 tions written in plain language explaining 7 how individuals may search for information 8 described in clause (ii) in files submitted in 9 accordance with clause (iii). 10 ‘‘(F) DEFINITIONS.—In this paragraph: 11 ‘‘(i) PARTICIPATING PROVIDER.—The 12 term ‘participating provider’ has the mean- 13 ing given such term in section 2799A–1 of 14 the Public Health Service Act. 15 ‘‘(ii) IN-NETWORK RATE.—The term 16 ‘in-network rate’ means, with respect to a 17 health plan and an item or service fur- 18 nished by a provider that is a participating 19 provider with respect to such plan and 20 item or service, the contracted rate in ef- 21 fect between such plan and such provider 22 for such item or service. If the rate is 23 based on an algorithm, percentage of an- 24 other amount, or other formula or criteria, 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00103 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 104 •S 3389 IS the health plan also shall disclose such al- 1 gorithm, percentage, formula, or criteria as 2 set forth in its contract and any other 3 terms, schedules, exhibits, data, or other 4 information referenced in any such con- 5 tract as shall be required to determine and 6 disclose the negotiated rate. 7 ‘‘(G) APPLICABILITY TO ACCOUNTABLE 8 CARE ORGANIZATIONS.—An applicable ACO 9 participating in the Medicare Shared Savings 10 Program, as defined in Section 1899 of the So- 11 cial Security Act (42 U.S.C. 1395jjj), shall be 12 subject to the requirements of this paragraph 13 as if such applicable ACO is a group health 14 plan or health insurance issuer. 15 ‘‘(H) ENFORCEMENT.— 16 ‘‘(i) IN GENERAL.—Each year, the 17 Secretary shall audit the three machine- 18 readable files required by subparagraph 19 (E)(ii) posted by no fewer than 20 group 20 health plans or health insurance issuers. 21 ‘‘(ii) NOTIFICATION AND REQUEST 22 FOR CORRECTIVE ACTION.—In the case of 23 a health plan that fails to comply with the 24 requirements of this subsection, not later 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00104 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 105 •S 3389 IS than 30 days after the date on which the 1 Secretary determines such failure exists, 2 the Secretary shall submit to such health 3 plan a notification of such determination, 4 which shall include a request for a correc- 5 tive action plan to comply with such re- 6 quirements. 7 ‘‘(iii) CIVIL MONETARY PENALTY.—A 8 health plan that has received a request for 9 a corrective action plan under clause (ii) 10 and fails to comply with the requirements 11 of this subsection by the date that is 90 12 days after such request is made shall be 13 subject to a civil monetary penalty of an 14 amount specified by the Secretary for each 15 day (beginning with the day on which the 16 Secretary first determined that such lab- 17 oratory was failing to comply with such 18 paragraph) during which such failure was 19 ongoing. Such amount shall not exceed 20 $300 per member per day or $10,000,000, 21 whichever is lesser. 22 ‘‘(I) RULEMAKING.—The Secretary shall 23 implement subparagraphs (E) through (H) 24 through notice and comment rulemaking in ac- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00105 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 106 •S 3389 IS cordance with section 553 of title 5, United 1 States Code.’’. 2 (c) EFFECTIVE DATE.— 3 (1) IN GENERAL.—The amendments made by 4 subsections (a) and (b) shall apply beginning Janu- 5 ary 1, 2026. 6 (2) CONTINUED APPLICABILITY OF RULES FOR 7 PREVIOUS YEARS.—Nothing in the amendments 8 made by this section may be construed as affecting 9 the applicability of the rule entitled ‘‘Transparency 10 in Coverage’’ published by the Department of the 11 Treasury, the Department of Labor, and the De- 12 partment of Health and Human Services on Novem- 13 ber 12, 2020 (85 Fed. Reg. 72158), before January 14 1, 2026. 15 SEC. 206. INCREASING GROUP HEALTH PLAN ACCESS TO 16 HEALTH DATA. 17 (a) GROUP HEALTH PLAN ACCESS TO INFORMA- 18 TION.— 19 (1) IN GENERAL.—Paragraph (2) of section 20 408(b) of the Employee Retirement Income Security 21 Act of 1974 (29 U.S.C. 1108(b)) is amended by 22 adding at the end the following new subparagraphs: 23 ‘‘(C) No contract or arrangement for services, 24 and no extension or renewal of such contract or ar- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00106 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 107 •S 3389 IS rangement, between a group health plan (as that 1 term is defined in section 733(a) of this title) and 2 party in interest, including a health care provider 3 (which for purposes of this subparagraph, includes a 4 health care facility), network or association of pro- 5 viders, service provider offering access to a network 6 of providers, third-party administrator, or pharmacy 7 benefit manager (collectively referred to as ‘Covered 8 Service Providers’), is reasonable within the meaning 9 of this paragraph unless such contract or arrange- 10 ment— 11 ‘‘(i) allows the responsible plan fiduciary 12 (as that term is defined in subparagraph 13 (B)(ii)(I)(ee)) access to all claims and encoun- 14 ter information or data, and any documentation 15 supporting claim payments, including, but not 16 limited to, medical records and policy docu- 17 ments, or information or data described in sec- 18 tion 724(a)(1)(B) to— 19 ‘‘(I) enable such entity to comply with 20 the terms of the plan and any applicable 21 law; and 22 ‘‘(II) determine the accuracy or rea- 23 sonableness of payment; and 24 ‘‘(ii) does not— 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00107 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 108 •S 3389 IS ‘‘(I) unreasonably limit or delay ac- 1 cess, as determined by the Secretary but in 2 any event not longer than 15 days, to such 3 information or data; 4 ‘‘(II) limit the volume of claims and 5 encounter information or data that the 6 group health plan, the plan sponsor, the 7 plan administrator, or a business associate 8 of such plan may access during an audit or 9 pursuant to any request for such informa- 10 tion or data; 11 ‘‘(III) limit the disclosure of pricing 12 terms for value-based payment arrange- 13 ments or capitated payment arrangements, 14 including— 15 ‘‘(aa) payment calculations and 16 formulas; 17 ‘‘(bb) quality measures; 18 ‘‘(cc) contract terms; 19 ‘‘(dd) payment amounts; 20 ‘‘(ee) measurement periods for all 21 incentives; and 22 ‘‘(ff) other payment methodolo- 23 gies used by an entity, including a 24 health care provider (including a 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00108 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 109 •S 3389 IS health care facility), network or asso- 1 ciation of providers, service provider 2 offering access to a network of pro- 3 viders, third-party administrator, or 4 pharmacy benefit manager; 5 ‘‘(IV) limit the disclosure of overpay- 6 ments and overpayment recovery terms; 7 ‘‘(V) limit the right of the group 8 health plan, the plan sponsor, or the plan 9 administrator of such plan to select an 10 auditor or define audit scope or frequency; 11 ‘‘(VI) otherwise limit or unduly delay 12 the group health plan, the plan sponsor, 13 the plan administrator, or a business asso- 14 ciate of such plan from accessing claims 15 and encounter information or data in a 16 daily batch; 17 ‘‘(VII) limit the disclosure of fees 18 charged to the group health plan related to 19 plan administration and claims processing, 20 including renegotiation fees, access fees, 21 repricing fees, or enhanced review fees; 22 ‘‘(VIII) limit the right of the group 23 health plan, the plan sponsor, or the plan 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00109 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 110 •S 3389 IS administrator to request action on any sus- 1 pect claim payments; or 2 ‘‘(IX) limit public disclosure of de- 3 identified or aggregate information. 4 ‘‘(D)(i) Covered Service Providers shall provide 5 information or data under this paragraph in a man- 6 ner consistent with the privacy and security regula- 7 tions promulgated under the Health Insurance Port- 8 ability and Accountability Act (referred to in this 9 subparagraph as ‘HIPAA’). 10 ‘‘(ii) A group health plan that receives a disclo- 11 sure from a party in interest pursuant to subpara- 12 graph (B) or (C) shall comply with the privacy and 13 security regulations promulgated under HIPAA. 14 ‘‘(iii) Nothing in this subparagraph shall be 15 construed to modify the requirements for the cre- 16 ation, receipt, maintenance, or transmission of pro- 17 tected health information under the HIPAA privacy 18 regulation (as defined in section 1180(b)(3) of the 19 Social Security Act) as they apply directly or indi- 20 rectly to an entity pursuant to this paragraph. 21 ‘‘(iv) This subparagraph shall not be read to 22 abridge or limit the disclosure requirements under 23 this paragraph or to impose additional privacy or se- 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00110 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 111 •S 3389 IS curity requirements on Covered Service Providers or 1 plan sponsors. 2 ‘‘(E) A group health plan receiving information 3 or data under this paragraph may disclose such in- 4 formation only in a manner that is consistent with 5 the Health Insurance Portability and Accountability 6 Act (HIPAA) and the privacy and security regula- 7 tions promulgated thereunder, regardless of their di- 8 rect or indirect applicability to the plan or any enti- 9 ties that could be or are business associates. 10 ‘‘(F) Information made available under this sec- 11 tion shall conform to the following standards: 12 ‘‘(i) All claims from a healthcare provider 13 shall be made to the group health plan in ac- 14 cordance with transaction standards adopted by 15 regulation under HIPAA, as follows: 16 ‘‘(I) Institutional, professional, and 17 dental claims shall be in ASC X12N 837 18 format or any subsequent standard. 19 ‘‘(II) Pharmacy claims shall be in the 20 National Council for Prescription Drug 21 Programs (NCPDP) format or any subse- 22 quent standard. 23 ‘‘(III) The files shall be unmodified 24 copies of the files sent from the provider. 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00111 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 112 •S 3389 IS In the event that paper claims are sent by 1 the provider, they shall be converted to the 2 appropriate standard electronic format. 3 Files shall be accessible to the plan at no 4 cost to the group health plan. 5 ‘‘(ii) All claim payment (or EFT, electronic 6 funds transfer) and electronic remittance advice 7 (ERA) notices sent by a Covered Service Pro- 8 vider shall be made available to the group 9 health plan as ASC X12N 835 files in accord- 10 ance with standards adopted by regulation 11 under HIPAA. The files shall be unmodified 12 copies of the files sent by the Covered Service 13 Provider to the healthcare provider. Files shall 14 be accessible at no cost to the group health 15 plan. 16 ‘‘(iii) The contractual terms containing cal- 17 culation formulae, pricing methodologies, and 18 other information used to determine the dollar 19 value of reimbursement. 20 ‘‘(iv) All non-claim costs shall be itemized 21 and made available to the group health plan in 22 real time through a web-based portal, through 23 an API, and through a downloadable CSV file. 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00112 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 113 •S 3389 IS ‘‘(G) The Secretary shall implement subpara- 1 graphs (C) through (F) through notice and comment 2 rulemaking in accordance with section 553 of title 5, 3 United States Code.’’. 4 (2) CIVIL ENFORCEMENT.—Subsection (c) of 5 section 502 of such Act (29 U.S.C. 1132) is amend- 6 ed by adding at the end the following new para- 7 graph: 8 ‘‘(13) In the case of an agreement between a group 9 health plan (as defined in section 733(a)), the plan spon- 10 sor of such plan (as defined in section 3(16)(B)), or the 11 plan administrator of such plan (as defined in section 12 3(16)(A)) and a health care provider (which, for purposes 13 of this paragraph, includes a health care facility), network 14 or association of providers, service provider offering access 15 to a network or association of providers, third-party ad- 16 ministrator, or pharmacy benefit manager, that violates 17 the provisions of section 724, the Secretary may assess 18 a civil penalty against such provider, network or associa- 19 tion, service provider offering access to a network or asso- 20 ciation of providers, third-party administrator, pharmacy 21 benefit manager, or other service provider in the amount 22 of $10,000 for each day during which such violation con- 23 tinues. Such penalty shall be in addition to other penalties 24 as may be prescribed by law.’’. 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00113 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 114 •S 3389 IS (3) EXISTING PROVISIONS VOID.—Section 410 1 of such Act (29 U.S.C. 1110) is amended by adding 2 at the end the following: 3 ‘‘(c) Any provision in an agreement or instrument 4 shall be void as against public policy if such provision— 5 ‘‘(1) unduly delays or limits a group health plan 6 (as defined in section 733(a)), the plan sponsor of 7 such plan (as defined in section 3(16)(B)), or the 8 plan administrator of such plan (as defined in sec- 9 tion 3(16)(A)) from accessing the claims and en- 10 counter information or data described in section 11 724(a)(1)(B); or 12 ‘‘(2) violates the requirements of section 13 408(b)(2)(C).’’. 14 (4) TECHNICAL AMENDMENT.—Clause (i) of 15 section 408(b)(2)(B) of such Act is amended by 16 striking ‘‘this clause’’ and inserting ‘‘this para- 17 graph’’. 18 (b) UPDATED ATTESTATION FOR PRICE AND QUAL- 19 ITY INFORMATION.—Section 724(a)(3) of the Employee 20 Retirement Income Security Act of 1974 (29 U.S.C. 21 1185m(a)(3)) is amended to read as follows: 22 ‘‘(3) ATTESTATION.— 23 ‘‘(A) IN GENERAL.—Subject to subpara- 24 graph (C), a group health plan or health insur- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00114 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 115 •S 3389 IS ance issuer offering group health insurance cov- 1 erage shall annually submit to the Secretary an 2 attestation that such plan or issuer of such cov- 3 erage is in compliance with the requirements of 4 this subsection. Such attestation shall also in- 5 clude a statement verifying that— 6 ‘‘(i) the information or data described 7 under subparagraphs (A) and (B) of para- 8 graph (1) is available upon request and 9 provided to the group health plan, the plan 10 sponsor, the plan administrator, or the 11 business associate of such plan, or the 12 issuer in a timely manner; and 13 ‘‘(ii) there are no terms in the agree- 14 ment under such paragraph (1) that di- 15 rectly or indirectly restrict or unduly delay 16 a group health plan, the plan sponsor, the 17 plan administrator, a business associate of 18 such plan, or the issuer from auditing, re- 19 viewing, or otherwise accessing such infor- 20 mation. 21 ‘‘(B) LIMITATION ON SUBMISSION.—Sub- 22 ject to clause (ii), a group health plan or issuer 23 offering group health insurance coverage may 24 not enter into an agreement with a third-party 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00115 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 116 •S 3389 IS administrator or other service provider to sub- 1 mit the attestation required under subpara- 2 graph (A). 3 ‘‘(C) EXCEPTION.—In the case of a group 4 health plan or issuer offering group health in- 5 surance coverage that is unable to obtain the 6 information or data needed to submit the attes- 7 tation required under subparagraph (A), such 8 plan or issuer may submit a written statement 9 in lieu of such attestation that includes— 10 ‘‘(i) an explanation of why such plan 11 or issuer was unsuccessful in obtaining 12 such information or data, including wheth- 13 er such plan, the plan sponsor, or the plan 14 administrator or issuer was limited or pre- 15 vented from auditing, reviewing, or other- 16 wise accessing such information or data; 17 ‘‘(ii) a description of the efforts made 18 by the group health plan, the plan sponsor, 19 or the plan administrator to remove any 20 gag clause provisions from the agreement 21 under paragraph (1); and 22 ‘‘(iii) a description of any response by 23 the third-party administrator or other serv- 24 ice provider with respect to efforts to com- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00116 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 117 •S 3389 IS ply with the attestation requirement under 1 subparagraph (A), including the name of 2 the third-party administrator or other serv- 3 ice provider.’’. 4 (c) EFFECTIVE DATE.—The amendments made by 5 subsections (a) and (b) shall apply with respect to a plan 6 beginning with the first plan year that begins on or after 7 the date that is 1 year after the date of enactment of this 8 Act. 9 SEC. 207. OVERSIGHT OF ADMINISTRATIVE SERVICE PRO- 10 VIDERS. 11 (a) ERISA AMENDMENTS.— 12 (1) IN GENERAL.—Subpart B of part 7 of sub- 13 title B of the Employee Retirement Income Security 14 Act of 1974 (29 U.S.C. 1021 et seq.) is amended by 15 adding at the end the following: 16 ‘‘SEC. 726. OVERSIGHT OF ADMINISTRATIVE SERVICE PRO- 17 VIDERS. 18 ‘‘(a) IN GENERAL.—For plan years beginning on or 19 after the date that is 2 years after the date of enactment 20 of this section, no agreement between a group health plan 21 (as defined in section 733(a)), the plan sponsor of such 22 plan (as defined in section 3(16)(B)), the plan adminis- 23 trator of such plan (as defined in section 3(16)(A)), or 24 a business associate of such plan (as defined in section 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00117 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 118 •S 3389 IS 160.103 of title 45, Code of Federal Regulations), (or 1 health insurance issuer offering group health insurance 2 coverage in connection with such a plan), and a health 3 care provider, network or association of providers, third- 4 party administrator, service provider offering access to a 5 network of providers, pharmacy benefit managers, or any 6 other third party (each referred to as a ‘health plan service 7 provider’) is permissible if such agreement limits (or 8 delays beyond the applicable reporting period described in 9 subsection (b)(1)) the disclosure of information to group 10 health plans in such a manner that prevents such plan, 11 issuer, or entity from providing the information described 12 in subsection (b). 13 ‘‘(b) REQUIRED DISCLOSURES.— 14 ‘‘(1) CONTENTS AND FREQUENCY.—With re- 15 spect to plan years beginning on or after the date 16 that is 2 years after the date of enactment of this 17 section, not less frequently than quarterly, a health 18 plan service provider shall provide to the group 19 health plan or health insurance issuer the following 20 information at no cost to the group health plan or 21 health insurance issuer: 22 ‘‘(A) The information described in section 23 724(a)(1)(B). 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00118 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 119 •S 3389 IS ‘‘(B) Any contractual and subcontractual 1 calculation methodologies, pricing or fee sched- 2 ules, or other formulae used to determine reim- 3 bursement amounts to providers and sub- 4 contractors, including methodologies, schedules, 5 fee structures, and any applied adjustments or 6 modifiers, with such information provided in a 7 manner sufficiently detailed to enable the group 8 health plan or health insurance issuer to accu- 9 rately assess, verify, and ensure compliance 10 with the terms of any contractual and sub- 11 contractual agreement governing the reimburse- 12 ment amounts. 13 ‘‘(C) The total amount received or ex- 14 pected to be received by the health plan service 15 provider or its subcontractors in provider or 16 supplier rebates, fees, alternative discounts, and 17 all other remuneration including amounts held 18 in escrow or variance accounts that has been 19 paid or is to be paid for claims incurred and 20 administrative services including data sales or 21 network payments. 22 ‘‘(D) The total amount paid or expected to 23 be paid by the health plan service provider or 24 to subcontractors in rebates, fees, contractual 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00119 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 120 •S 3389 IS arrangements, and all other remuneration that 1 has been paid or is expected to be paid for ad- 2 ministrative and other services. 3 ‘‘(E) All payment data and reconciliation 4 information related to alternative compensation 5 arrangements including accountable care orga- 6 nizations, value-based programs, shared savings 7 programs, incentive compensation, bundled pay- 8 ments, capitation arrangements, performance 9 payments, and any other reimbursement or pay- 10 ment models, where the group health plan or 11 health insurance issuer paid fees, incurred obli- 12 gations, or made payments in connection with 13 the group health plan related to such arrange- 14 ments. 15 ‘‘(2) PRIVACY REQUIREMENTS.— 16 ‘‘(A) IN GENERAL.—Health plan service 17 providers shall provide the information or data 18 under paragraph (1) consistent with the pri- 19 vacy, security, and breach notification regula- 20 tions at parts 160 and 164 of title 45, Code of 21 Federal Regulations, promulgated under sub- 22 title F of the Health Insurance Portability and 23 Accountability Act of 1996, subtitle D of the 24 Health Information Technology for Clinical 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00120 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 121 •S 3389 IS Health Act of 2009, and section 1180 of the 1 Social Security Act, and shall restrict the use 2 and disclosure of such information according to 3 such privacy, security, and breach notification 4 regulations. An entity that receives a disclosure 5 from a party in interest pursuant to subpara- 6 graph (B) or (C) shall comply with the privacy 7 and security regulations promulgated under 8 HIPAA. 9 ‘‘(B) RESTRICTIONS.—A group health plan 10 shall comply with section 164.504(f) of title 45, 11 Code of Federal Regulations (or a successor 12 regulation), and a plan sponsor shall act in ac- 13 cordance with the terms of the agreement de- 14 scribed in such section. 15 ‘‘(C) RULE OF CONSTRUCTION.—Nothing 16 in this section shall be construed to modify the 17 requirements for the creation, receipt, mainte- 18 nance, or transmission of protected health in- 19 formation under the HIPAA privacy regulations 20 (45 CFR parts 160 and 164, subparts A and 21 E). 22 ‘‘(3) DISCLOSURE AND REDISCLOSURE.— 23 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00121 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 122 •S 3389 IS ‘‘(A) IN GENERAL.—A group health plan 1 receiving information under paragraph (1) may 2 disclose such information only— 3 ‘‘(i) to the entity from which the in- 4 formation was received or to that entity’s 5 business associates or to the group health 6 plan’s business associates as defined in 7 section 160.103 of title 45, Code of Fed- 8 eral Regulations (or successor regulations); 9 or 10 ‘‘(ii) as permitted by the HIPAA Pri- 11 vacy Rule (45 CFR parts 160 and 164, 12 subparts A and E). 13 ‘‘(B) AVAILABILITY OF INFORMATION.—To 14 the extent the information required by this sub- 15 section is made available to the health insur- 16 ance issuer offering group health insurance in 17 connection with a group health plan, the health 18 insurance issuer shall make such information 19 available, at the same time, in the same format, 20 and at no cost, to the group health plan. 21 ‘‘(C) FAILURE TO PROVIDE.—The obliga- 22 tion to provide information pursuant to this 23 subsection shall exist notwithstanding the pres- 24 ence of any formal data-sharing agreement be- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00122 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 123 •S 3389 IS tween the parties. Failure to provide the re- 1 quired information as specified shall constitute 2 a violation of this Act and the Secretary shall 3 initiate enforcement action under section 502 4 within 90 days of becoming aware of a violation 5 of this section, except that nothing in this sec- 6 tion shall be construed to limit the Secretary’s 7 existing authority under the Act. 8 ‘‘(4) DATA FORMAT STANDARDS.—All data and 9 information provided pursuant to this subsection 10 shall comply with the following standards: 11 ‘‘(A) All claims from a healthcare provider 12 shall be made to the group health plan in ac- 13 cordance with transactions standards adopted 14 under HIPAA, as follows: 15 ‘‘(i) Institutional, professional, and 16 dental claims and adjustments to these 17 claims shall be in ASC X12N 837 format, 18 as transmitted by the provider, or, in the 19 case of paper claims, converted to the ASC 20 X12N 837 electronic format. 21 ‘‘(ii) Prescription drug claims shall be 22 in the National Council for Prescription 23 Drug Programs (NCPDP) format, as 24 transmitted by the provider, or in the case 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00123 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 124 •S 3389 IS of paper claims, converted to the NCPDP 1 electronic format. 2 ‘‘(iii) Such data shall be provided at 3 no cost to the group health plan. 4 ‘‘(B) All claim payment (or EFT, elec- 5 tronic funds transfer) and electronic remittance 6 advice (ERA) information sent by a health plan 7 service provider shall be provided to the group 8 health plan or health insurance issuer in the 9 ASC X12N 835 format in accordance with 10 transaction standards adopted under HIPAA, 11 unmodified from the form in which it was 12 transmitted to the healthcare provider. Such in- 13 formation shall be provided at no cost to the 14 group health plan or health insurance issuer. 15 ‘‘(C) The Secretary may modify the stand- 16 ards set forth in this paragraph as necessary to 17 align with any changes adopted by the Sec- 18 retary of Health and Human Services pursuant 19 to the authority provided under section 1173 of 20 the Social Security Act (42 U.S.C. 1320d–2). 21 ‘‘(c) PROHIBITED CONTRACTUAL PROVISIONS.—Any 22 provision in an agreement between a group health plan, 23 the plan sponsor, the plan administrator, or a business 24 associate of such plan or a health insurance issuer and 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00124 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 125 •S 3389 IS a health plan service provider that unduly delays or limits 1 a group health plan’s or health insurance issuer’s access 2 to information described in this section or that restricts 3 the format or timing of the provision of such information 4 in a manner that is inconsistent with the requirements of 5 this section shall be prohibited and, if a group health plan 6 or health insurance issuer enters into such agreement, 7 shall be deemed void as against public policy. 8 ‘‘(d) PENALTIES FOR NON-COMPLIANCE.—Any fail- 9 ure by a health plan service provider to comply with the 10 requirements of this section shall result in the imposition 11 of a civil penalty of $100,000 for each day the violation 12 continues, in addition to any other penalties prescribed by 13 law. 14 ‘‘(e) REGULATIONS.—The Secretary shall implement 15 this section through notice and comment rulemaking in 16 accordance with section 553 of title 5, United States 17 Code.’’. 18 (2) PENALTY.— 19 (A) IN GENERAL.—Section 502(c) of the 20 Employee Retirement Income Security Act of 21 1974 (29 U.S.C. 1132(c)), as amended by sec- 22 tion 206, is further amended by adding at the 23 end the following new paragraph: 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00125 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 126 •S 3389 IS ‘‘(14) The Secretary may assess a civil penalty 1 against any person of $100,000 per day for each violation 2 by any person of section 726.’’. 3 (B) TECHNICAL AMENDMENT.—Paragraph 4 (6) of section 502(a) of the Employee Retire- 5 ment Income Security Act of 1974 (29 U.S.C. 6 1132(a)) is amended by striking ‘‘or (9)’’ and 7 inserting ‘‘(9), (13), or (14)’’. 8 (b) PHSA AMENDMENTS.— 9 (1) IN GENERAL.—Part D of title XXVII of the 10 Public Health Service Act (42 U.S.C. 300gg–111 et 11 seq.) is amended by adding at the end the following: 12 ‘‘SEC. 2799A–11. OVERSIGHT OF ADMINISTRATIVE SERVICE 13 PROVIDERS. 14 ‘‘(a) IN GENERAL.—For plan years beginning on or 15 after the date that is 1 year after the date of enactment 16 of this section, no agreement between a group health plan 17 that is a self-funded, non-Federal governmental plan, as 18 defined in section 2791(d)(8)(C), and a health care pro- 19 vider, network or association of providers, third-party ad- 20 ministrator, service provider offering access to a network 21 of providers, pharmacy benefit managers, or any other 22 third party (each referred to in this section as a ‘health 23 plan service provider’) is permissible if such agreement 24 limits (or delays beyond the applicable reporting period de- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00126 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 127 •S 3389 IS scribed in subsection (b)(1)) the disclosure of information 1 to group health plans in such a manner that prevents such 2 plan, issuer, or entity from providing the information de- 3 scribed in subsection (b). 4 ‘‘(b) REQUIRED DISCLOSURES.— 5 ‘‘(1) CONTENTS AND FREQUENCY.—With re- 6 spect to plan years beginning on or after the date 7 that is 1 year after the date of enactment of this 8 section, not less frequently than quarterly, a health 9 plan service provider shall provide to the group 10 health plan that is a self-funded, non-Federal gov- 11 ernmental plan the following information at no cost 12 to the plan: 13 ‘‘(A) The information described in section 14 2799A–9(a)(1)(B). 15 ‘‘(B) Any contractual and subcontractual 16 calculation methodologies, pricing or fee sched- 17 ules, or other formulae used to determine reim- 18 bursement amounts to providers and sub- 19 contractors, including methodologies, schedules, 20 fee structures, and any applied adjustments or 21 modifiers, with such information provided in a 22 manner sufficiently detailed to enable the group 23 health plan to accurately assess, verify, and en- 24 sure compliance with the terms of any contrac- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00127 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 128 •S 3389 IS tual and subcontractual agreement governing 1 the reimbursement amounts. 2 ‘‘(C) The total amount received or ex- 3 pected to be received by the health plan service 4 provider or its subcontractors in provider or 5 supplier rebates, fees, alternative discounts, and 6 all other remuneration including amounts held 7 in escrow or variance accounts that has been 8 paid or is to be paid for claims incurred and 9 administrative services including data sales or 10 network payments. 11 ‘‘(D) The total amount paid or expected to 12 be paid by the health plan service provider or 13 to subcontractors in rebates, fees, contractual 14 arrangements, and all other remuneration that 15 has been paid or is expected to be paid for ad- 16 ministrative and other services. 17 ‘‘(E) All payment data and reconciliation 18 information related to alternative compensation 19 arrangements including accountable care orga- 20 nizations, value-based programs, shared savings 21 programs, incentive compensation, bundled pay- 22 ments, capitation arrangements, performance 23 payments, and any other reimbursement or pay- 24 ment models, where the group health plan paid 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00128 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 129 •S 3389 IS fees, incurred obligations, or made payments in 1 connection with the group health plan related to 2 such arrangements. 3 ‘‘(2) PRIVACY REQUIREMENTS.— 4 ‘‘(A) IN GENERAL.—Health plan service 5 providers shall provide the information or data 6 under paragraph (1) consistent with the pri- 7 vacy, security, and breach notification regula- 8 tions at parts 160 and 164 of title 45, Code of 9 Federal Regulations, promulgated under sub- 10 title F of the Health Insurance Portability and 11 Accountability Act of 1996, subtitle D of the 12 Health Information Technology for Clinical 13 Health Act of 2009, and section 1180 of the 14 Social Security Act, and shall restrict the use 15 and disclosure of such information according to 16 such privacy, security, and breach notification 17 regulations. An entity that receives a disclosure 18 from a party in interest pursuant to subpara- 19 graph (B) or (C) shall comply with the privacy 20 and security regulations promulgated under 21 HIPAA. 22 ‘‘(B) RESTRICTIONS.—A group health plan 23 that is a self-funded, non-Federal governmental 24 plan shall comply with section 164.504(f) of 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00129 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 130 •S 3389 IS title 45, Code of Federal Regulations (or a suc- 1 cessor regulation), and a plan sponsor shall act 2 in accordance with the terms of the agreement 3 described in such section. 4 ‘‘(C) RULE OF CONSTRUCTION.—Nothing 5 in this section shall be construed to modify the 6 requirements for the creation, receipt, mainte- 7 nance, or transmission of protected health in- 8 formation under the HIPAA privacy regulations 9 (parts 160 and 164 of title 45, Code of Federal 10 Regulations). 11 ‘‘(3) DISCLOSURE AND REDISCLOSURE.— 12 ‘‘(A) IN GENERAL.—A group health plan 13 that is a self-funded, non-Federal governmental 14 plan receiving information under paragraph (1) 15 may disclose such information only— 16 ‘‘(i) to the entity from which the in- 17 formation was received or to that entity’s 18 business associates as defined in section 19 160.103 of title 45, Code of Federal Regu- 20 lations (or successor regulations); or 21 ‘‘(ii) as permitted by the HIPAA Pri- 22 vacy Rule (45 CFR parts 160 and 164, 23 subparts A and E). 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00130 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 131 •S 3389 IS ‘‘(B) RULE OF CONSTRUCTION.—Nothing 1 in this section shall be construed to prevent a 2 group health plan that is a self-funded, non- 3 Federal governmental plan, or a health plan 4 service provider providing services with respect 5 to such a plan, from placing reasonable restric- 6 tions on the public disclosure of the information 7 described in paragraph (1), except that such 8 plan or entity may not restrict disclosure of 9 such information to the Department of Health 10 and Human Services, the Department of Labor, 11 the Department of the Treasury, or the Comp- 12 troller General of the United States. 13 ‘‘(C) FAILURE TO PROVIDE.—The obliga- 14 tion to provide information pursuant to this 15 subsection shall exist notwithstanding the pres- 16 ence of any formal data-sharing agreement be- 17 tween the parties. Failure to provide the re- 18 quired information as specified shall constitute 19 a violation of this Act and the Secretary shall 20 initiate enforcement action under section 21 2723(b) within 90 days of becoming aware of a 22 violation of this section, except that nothing in 23 this section shall be construed to limit the Sec- 24 retary’s existing authority under this Act. 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00131 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 132 •S 3389 IS ‘‘(4) DATA FORMAT STANDARDS.—All data and 1 information provided pursuant to this subsection 2 shall comply with the following standards: 3 ‘‘(A) All claims from a healthcare provider 4 shall be made to the group health plan in ac- 5 cordance with standards adopted under HIPAA 6 at section 162.1101 of title 45, Code of Federal 7 Regulations, as follows: 8 ‘‘(i) Institutional, professional, and 9 dental claims and adjustments to these 10 claims shall be provided to the group 11 health plan that is a self-funded, non-Fed- 12 eral governmental plan in the ASC X12N 13 837 format. 14 ‘‘(ii) Prescription drug claims shall be 15 in the National Council for Prescription 16 Drug Programs (NCPDP) format. 17 ‘‘(iii) The files shall be unmodified 18 copies of the files sent from the provider. 19 In the event that paper claims are sent by 20 the provider, they shall be converted to the 21 appropriate standard electronic format. 22 Such data shall be provided at no cost to 23 the group health plan. 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00132 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 133 •S 3389 IS ‘‘(B) All claim payment (or EFT, elec- 1 tronic funds transfer) and electronic remittance 2 advice (ERA) information sent by a health plan 3 service provider shall be provided to the group 4 health plan or health insurance issuer in the 5 ASC X12N 835 format, in accordance with 6 standards adopted under HIPAA at section 7 162.1602 of title 45, Code of Federal Regula- 8 tions, unmodified from the form in which it was 9 transmitted to the healthcare provider. Such in- 10 formation shall be provided at no cost to the 11 group health plan. 12 ‘‘(C) The Secretary may modify the stand- 13 ards set forth in this paragraph as necessary to 14 align with any changes adopted by the Sec- 15 retary pursuant to the authority provided under 16 section 1173 of the Social Security Act. 17 ‘‘(c) PROHIBITED CONTRACTUAL PROVISIONS.—Any 18 provision in an agreement that unduly delays or limits a 19 group health plan that is a self-funded, non-Federal gov- 20 ernmental plan’s access to information described in this 21 section or that restricts the format or timing of the provi- 22 sion of such information in a manner that is inconsistent 23 with the requirements of this section shall be prohibited 24 and, if a self-funded, non-Federal governmental plan en- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00133 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 134 •S 3389 IS ters into such agreement, shall be deemed void as against 1 public policy. 2 ‘‘(d) REGULATIONS.—The Secretary shall implement 3 this section through notice and comment rulemaking in 4 accordance with section 553 of title 5, United States 5 Code.’’. 6 (2) PENALTY.—Section 2723(b) of the Public 7 Health Service Act (42 U.S.C. 300gg–22(b)) is 8 amended by adding at the end the following: 9 ‘‘(4) ENFORCEMENT AUTHORITY RELATING TO 10 HEALTH PLAN SERVICE PROVIDERS.—Notwith- 11 standing any provisions to the contrary, the Sec- 12 retary may assess a penalty against a health plan 13 service provider, as defined in section 2799A–11(a), 14 of $100,000 per day for each violation of such sec- 15 tion, pursuant to substantially similar processes and 16 procedures as those set forth in subparagraphs (D) 17 through (G) of section 2723(b)(2).’’. 18 SEC. 208. STATE PREEMPTION ONLY IN EVENT OF CON- 19 FLICT. 20 The provisions of sections 201 through 204 (includ- 21 ing the amendments made by such sections) shall not su- 22 persede any provision of State law which establishes, im- 23 plements, or continues in effect any requirement or prohi- 24 bition related to health care price transparency, including 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00134 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 135 •S 3389 IS hospital, clinical diagnostic laboratory tests, imaging serv- 1 ices, and ambulatory surgical center, except to the extent 2 that such requirement or prohibition prevents the applica- 3 tion of a requirement or prohibition of such sections (or 4 amendment). Nothing in this section shall be construed 5 to affect group health plans established under the Em- 6 ployee Retirement Income Security Act of 1974, or alter 7 the application of section 514 of such Act (29 U.S.C. 8 1144). 9 SEC. 209. REQUIREMENT FOR EXPLANATION OF BENEFITS. 10 (a) PHSA AMENDMENTS.— 11 (1) EMERGENCY SERVICES.—Section 2799A– 12 1(f)(1)(C) of the Public Health Service Act (42 13 U.S.C. 300gg–111(f)(1)(C)) is amended to read as 14 follows: 15 ‘‘(C) A good faith estimate of the amount 16 the plan or coverage is responsible for paying 17 for items and services included in the estimate 18 described in subparagraph (B), including a 19 plain language description of each item or serv- 20 ice and all applicable billing codes for each item 21 or service, including modifiers, using standard 22 and commonly recognized billing code sets that 23 are clearly identified.’’. 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00135 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 136 •S 3389 IS (2) EXPLANATION OF BENEFITS.—Section 1 2799A–1 of the Public Health Service Act (42 2 U.S.C. 300gg–111) is amended by adding at the end 3 the following: 4 ‘‘(g) EXPLANATION OF BENEFITS.— 5 ‘‘(1) IN GENERAL.—For plan years beginning 6 on or after January 1, 2026, each group health 7 plan, or a health insurance issuer offering group or 8 individual health insurance coverage shall, within 45 9 days of receiving any request for payment for an 10 item or service under the plan, provide to the partic- 11 ipant, beneficiary, or enrollee (through mail or elec- 12 tronic means, as requested by the participant, bene- 13 ficiary, or enrollee) a notification (in clear and un- 14 derstandable language and utilizing substantially the 15 same format as the advanced explanation of benefits 16 required by subsection (f) to enable comparison) in- 17 cluding the following: 18 ‘‘(A) Whether or not the provider or facil- 19 ity is a participating provider or a participating 20 facility with respect to the plan or coverage 21 with respect to the furnishing of such item or 22 service. 23 ‘‘(B) An itemized explanation of benefits 24 that includes the following: 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00136 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 137 •S 3389 IS ‘‘(i) A plain language description of 1 each item or service. 2 ‘‘(ii) All applicable billing codes for 3 each item or service, including modifiers, 4 using standard and commonly recognized 5 billing code sets that are clearly identified. 6 ‘‘(iii) The amount the plan or cov- 7 erage is responsible for paying for each 8 item or service. 9 ‘‘(iv) The amount of any cost-sharing 10 for which the participant, beneficiary, or 11 enrollee is responsible for each item or 12 service (as of the date of such notification). 13 ‘‘(v) The amount that the participant, 14 beneficiary, or enrollee has incurred toward 15 meeting the limit of the financial responsi- 16 bility (including with respect to deductibles 17 and out-of-pocket maximums) under the 18 plan or coverage (as of the date of such 19 notification). 20 ‘‘(vi) The site of each item or service. 21 ‘‘(2) FORMAT.—If applicable, the notification 22 described in paragraph (1) may be provided in con- 23 junction with, or as part of, a notice of a claim de- 24 termination or other communication required by sec- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00137 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 138 •S 3389 IS tion 2719(a) (42 U.S.C. 300gg–19(a)), or regula- 1 tions thereunder. 2 ‘‘(h) REGULATIONS.—The Secretary shall implement 3 this section through notice and comment rulemaking in 4 accordance with section 553 of title 5, United States 5 Code.’’. 6 (b) IRC AMENDMENTS.— 7 (1) EMERGENCY SERVICES.—Section 8 9816(f)(1)(C) of the Internal Revenue Code of 1986 9 is amended to read as follows: 10 ‘‘(C) A good faith estimate of the amount 11 the plan is responsible for paying for items and 12 services included in the estimate described in 13 subparagraph (B), including a plain language 14 description of each item or service and all appli- 15 cable billing codes for each item or service, in- 16 cluding modifiers, using standard and com- 17 monly recognized billing code sets that are 18 clearly identified.’’. 19 (2) EXPLANATION OF BENEFITS.—Section 20 9816 of the Internal Revenue Code of 1986 is 21 amended by adding at the end the following: 22 ‘‘(g) EXPLANATION OF BENEFITS.— 23 ‘‘(1) IN GENERAL.—For plan years beginning 24 on or after January 1, 2026, each group health plan 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00138 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 139 •S 3389 IS shall, within 45 days of receiving any request for 1 payment for an item or service under the plan, pro- 2 vide to the participant or beneficiary (through mail 3 or electronic means, as requested by the participant 4 or beneficiary) a notification (in clear and under- 5 standable language and utilizing substantially the 6 same format as the advanced explanation of benefits 7 required by subsection (f) to enable comparison) in- 8 cluding the following: 9 ‘‘(A) Whether or not the provider or facil- 10 ity is a participating provider or a participating 11 facility with respect to the plan with respect to 12 the furnishing of such item or service. 13 ‘‘(B) An itemized explanation of benefits 14 that includes the following: 15 ‘‘(i) A plain language description of 16 each item or service. 17 ‘‘(ii) All applicable billing codes for 18 each item or service, including modifiers, 19 using standard and commonly recognized 20 billing code sets that are clearly identified. 21 ‘‘(iii) The amount the plan is respon- 22 sible for paying for each item or service. 23 ‘‘(iv) The amount of any cost-sharing 24 for which the participant or beneficiary is 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00139 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 140 •S 3389 IS responsible for each item or service (as of 1 the date of such notification). 2 ‘‘(v) The amount that the participant 3 or beneficiary has incurred toward meeting 4 the limit of the financial responsibility (in- 5 cluding with respect to deductibles and 6 out-of-pocket maximums) under the plan 7 (as of the date of such notification). 8 ‘‘(vi) The site of each item or service. 9 ‘‘(2) FORMAT.—If applicable, the notification 10 described in paragraph (1) may be provided in con- 11 junction with, or as part of, a notice of a claim de- 12 termination or other communication required by sec- 13 tion 503 of the Employee Retirement Income Secu- 14 rity Act of 1974 or regulations thereunder. 15 ‘‘(h) REGULATIONS.—The Secretary shall implement 16 this section through notice and comment rulemaking in 17 accordance with section 553 of title 5, United States 18 Code.’’. 19 (c) ERISA AMENDMENTS.— 20 (1) EMERGENCY SERVICES.—Section 21 716(f)(1)(C) of the Employee Retirement Income 22 Security Act of 1974 (29 U.S.C. 1185e(f)(1)(C)) is 23 amended to read as follows: 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00140 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 141 •S 3389 IS ‘‘(C) A good faith estimate of the amount 1 the health plan is responsible for paying for 2 items and services included in the estimate de- 3 scribed in subparagraph (B), including a plain 4 language description of each item or service and 5 all applicable billing codes for each item or serv- 6 ice, including modifiers, using standard and 7 commonly recognized billing code sets that are 8 clearly identified.’’. 9 (2) EXPLANATION OF BENEFITS.—Section 716 10 of the Employee Retirement Income Security Act of 11 1974 (29 U.S.C. 1185e) is amended by adding at 12 the end the following: 13 ‘‘(g) EXPLANATION OF BENEFITS.— 14 ‘‘(1) IN GENERAL.—For plan years beginning 15 on or after January 1, 2026, each group health plan 16 or health insurance issuer offering group health in- 17 surance coverage shall, within 45 days of receiving 18 any request for payment for an item or service 19 under the plan, provide to the participant or bene- 20 ficiary (through mail or electronic means, as re- 21 quested by the participant or beneficiary) a notifica- 22 tion (in clear and understandable language and uti- 23 lizing substantially the same format as the advanced 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00141 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 142 •S 3389 IS explanation of benefits required by subsection (f) to 1 enable comparison) including the following: 2 ‘‘(A) Whether or not the provider or facil- 3 ity is a participating provider or a participating 4 facility with respect to the plan or coverage 5 with respect to the furnishing of such item or 6 service. 7 ‘‘(B) An itemized explanation of benefits 8 that includes the following: 9 ‘‘(i) A plain language description of 10 each item or service. 11 ‘‘(ii) All applicable billing codes for 12 each item or service, including modifiers, 13 using standard and commonly recognized 14 billing code sets that are clearly identified. 15 ‘‘(iii) The amount the plan or cov- 16 erage is responsible for paying for each 17 item or service. 18 ‘‘(iv) The amount of any cost-sharing 19 for which the participant or beneficiary is 20 responsible for each item or service (as of 21 the date of such notification). 22 ‘‘(v) The amount that the participant 23 or beneficiary has incurred toward meeting 24 the limit of the financial responsibility (in- 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00142 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 143 •S 3389 IS cluding with respect to deductibles and 1 out-of-pocket maximums) under the plan 2 or coverage (as of the date of such notifi- 3 cation). 4 ‘‘(vi) The site of each item or service. 5 ‘‘(2) FORMAT.—If applicable, the notification 6 described in paragraph (1) may be provided in con- 7 junction with, or as part of, a notice of a claim de- 8 termination or other communication required by sec- 9 tion 503 or regulations thereunder. 10 ‘‘(h) REGULATIONS.—The Secretary shall implement 11 this section through notice and comment rulemaking in 12 accordance with section 553 of title 5, United States 13 Code.’’. 14 SEC. 210. PROVISION OF ITEMIZED BILLS. 15 Part E of title XXVII of the Public Health Service 16 Act (42 U.S.C. 300gg–131 et seq.) is amended by adding 17 at the end the following: 18 ‘‘SEC. 2799B–10. PROVIDER REQUIREMENTS FOR ITEMIZED 19 BILLS. 20 ‘‘(a) REQUIREMENTS.— 21 ‘‘(1) ITEMIZED BILL AND OTHER INFORMATION 22 REQUIRED.— 23 ‘‘(A) IN GENERAL.—A health care provider 24 or health care facility that requests payment 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00143 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 144 •S 3389 IS from an individual after providing a health care 1 item or service to the patient shall include with 2 such request a written, itemized bill of the cost 3 of each reasonably expected item or service the 4 health care provider or health care facility pro- 5 vided to the individual, including telehealth vis- 6 its or visits by other electronic means. The 7 health care provider or health care facility shall 8 provide the itemized bill not later than 30 days 9 after the health care provider or health care fa- 10 cility received a final payment on the provided 11 service or supply from a third party. 12 ‘‘(B) REQUIRED INFORMATION.—For each 13 item or service provided by the health care pro- 14 vider or facility or for which the health care 15 provider or facility is billing the individual, the 16 itemized bill must include— 17 ‘‘(i) a plain language description of 18 each distinct health care item or service; 19 ‘‘(ii) all applicable billing codes for 20 each distinct health care item or service, 21 including modifiers, using standard and 22 commonly recognized billing code sets that 23 are clearly identified; 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00144 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 145 •S 3389 IS ‘‘(iii) the price and billed amount, if 1 different, of each distinct health care item 2 or service or if the provider or facility is 3 offering binding, all-in prices for bundled 4 items and services, the total binding price 5 for bundled items and services and billed 6 amount; 7 ‘‘(iv) any payments made to the 8 health care provider or health care facility 9 by or on behalf of the individual (including 10 payments by any health plan or insurance) 11 for any health care item or service covered 12 in the itemized bill; 13 ‘‘(v) information about the availability 14 of language-assistance services for individ- 15 uals with limited English proficiency 16 (LEP); 17 ‘‘(vi) the identification of an office or 18 individual at the health care provider or 19 health care facility, including phone num- 20 ber and email address, that shall be able to 21 discuss the specific details of the itemized 22 statement and be authorized to make ap- 23 propriate changes thereto; and 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00145 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 146 •S 3389 IS ‘‘(vii) information about the health 1 care provider’s or health care facility’s 2 charity care policies and instructions on 3 how to apply for charity care. 4 ‘‘(2) COLLECTIONS ACTIONS.— 5 ‘‘(A) IN GENERAL.—A health care provider 6 or health care facility shall not take any collec- 7 tions actions against an individual— 8 ‘‘(i) for any provided health care item 9 or service unless the health care provider 10 or health care facility has complied with 11 paragraph (1); or 12 ‘‘(ii) with respect to any items or serv- 13 ices for which the amount appearing on an 14 itemized bill described above in paragraph 15 (1) exceeds the amount disclosed pursuant 16 to Federal health care price transparency 17 regulations, including part 180 of title 45, 18 Code of Federal Regulations, or provided 19 in a good faith estimate that complies with 20 section 2799B–6 of this Act and section 21 149.610 of title 45, Code of Federal Regu- 22 lations, or another good faith estimate pro- 23 vided by a health care entity covered under 24 this section but not otherwise covered 25 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00146 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 147 •S 3389 IS under such section 2799B–6 unless the 1 provider or facility documents that the ad- 2 ditional items or services were medically 3 necessary due to unforeseen complications 4 or a patient-initiated change, and could not 5 reasonably have been anticipated. 6 ‘‘(B) BURDEN OF PROOF.—The burden of 7 proof under subparagraph (A)(ii) shall rest with 8 the provider, and absent the documentation de- 9 scribed in such subparagraph, the good faith es- 10 timate shall be binding. 11 ‘‘(b) FAILURE TO COMPLY.— 12 ‘‘(1) PENALTIES.—The Secretary shall impose 13 penalties on any health care provider or health care 14 facility that fails to comply with the requirements of 15 this section in an amount not to exceed $10,000 for 16 each instance of failure to comply. 17 ‘‘(2) PRESUMPTION IN FAVOR OF INDI- 18 VIDUAL.—If a health care provider or health care fa- 19 cility fails to comply with the requirements of this 20 section, the presumption shall be that charges were 21 substantially in excess of the good faith estimate (as 22 set forth in section 2799B–6) for the purpose of any 23 patient-provider dispute, including in accordance 24 VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00147 Fmt 6652 Sfmt 6201 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB 148 •S 3389 IS with section 2799B–7 and regulations promulgated 1 thereunder. 2 ‘‘(c) REGULATIONS.—The Secretary shall implement 3 this section through notice and comment rulemaking in 4 accordance with section 553 of title 5, United States 5 Code.’’. 6 Æ VerDate Sep 11 2014 22:21 Dec 22, 2025 Jkt 069200 PO 00000 Frm 00148 Fmt 6652 Sfmt 6301 E:\BILLS\S3389.IS S3389 kjohnson on DSK7ZCZBW3PROD with $$_JOB