What changed between these versions
A complete substitute amendment. v2 fundamentally restructures the original bill by consolidating provider price transparency requirements under a new Public Health Service Act section, introducing extensive ownership disclosure mandates for providers and health plans, and significantly revising enforcement mechanisms, including a new "hold harmless" provision for patients. v2 is effectively a different bill from v1.
Overview
Extensive changes throughout the bill. · v2 fundamentally restructures and expands the scope of price transparency, data access, and enforcement, while also introducing new patient protections regarding billing discrepancies.
v2 is a complete substitute amendment that fundamentally reorganizes and expands the Patients Deserve Price Tags Act. The most significant change is the consolidation of hospital, clinical diagnostic laboratory, imaging services, and ambulatory surgical center price transparency requirements into a single new section of the Public Health Service Act (PHSA 2718A), alongside new mandates for ownership disclosure across these entities and health plans. Enforcement provisions are substantially revised, notably by introducing a limited waiver authority for civil monetary penalties and prohibiting extraordinary collection actions during periods of non-compliance. Additionally, v2 introduces new "hold harmless" provisions for patients when billed amounts exceed advanced explanations of benefits or good faith estimates.
Major additions
This new subsection introduces a consolidated set of definitions for terms used throughout the new provider price transparency section, including "applicable imaging service provider," "applicable laboratory," "discounted cash price," "extraordinary collection actions," "gross charge," "hospital," "payer-specific negotiated charge," "shoppable service," "specified ambulatory surgical center," "specified clinical diagnostic laboratory test," "specified imaging service," and "third party payer."
This centralizes definitions, providing a single reference point for key terms across hospital, laboratory, imaging, and ASC transparency requirements, which were previously defined separately within each section in v1. The inclusion of "extraordinary collection actions" is new and directly ties into new patient protection measures.
Requires hospitals to publicly disclose the name and business address of any person or entity that has an ownership or investment interest, a controlling interest, is a management services organization, or is a significant equity investor with respect to the hospital.
This is a new mandate for ownership transparency, aiming to provide consumers with a clearer understanding of the corporate structures behind healthcare providers. This could influence patient choice and potentially inform regulatory oversight regarding market concentration.
Prohibits hospitals from taking "extraordinary collection actions" against patients or guarantors for debt incurred during periods when the hospital was non-compliant with price transparency requirements. It also mandates ceasing any such actions already in progress and prevents future actions for that non-compliant period.
This is a significant new patient protection measure, directly linking hospital compliance with price transparency to their ability to pursue aggressive debt collection. It provides a tangible consequence for non-compliance that directly benefits patients.
These provisions extend the new ownership disclosure requirements to applicable clinical diagnostic laboratories, imaging service providers, and ambulatory surgical centers, respectively. They mandate public disclosure of entities with ownership, controlling, management services, or significant equity interests.
Broadens the scope of ownership transparency beyond hospitals to other key healthcare providers, providing a more comprehensive view of financial interests across the healthcare landscape.
Mandates that group health plans and health insurance issuers provide specific cost and coverage information to participants, beneficiaries, or enrollees at the time of enrollment.
This ensures individuals receive crucial transparency information proactively at a critical decision point, rather than only upon request or when seeking a specific service.
Requires group health plans and health insurance issuers to submit to the Secretary and make publicly available, on a quarterly basis, the name and business address of each person or entity that has an ownership or investment interest, a controlling interest, is a management services organization, or is a significant equity investor with respect to the plan or coverage.
This extends ownership transparency to the health insurance and plan administration sector, providing insights into the financial structures of entities responsible for coverage.
These clauses, part of the group health plan access to information, explicitly prohibit contracts from limiting the disclosure of whether a Covered Service Provider has an ownership/investment/controlling interest or is a management services organization/significant equity investor with respect to a provider. It also prohibits limiting disclosure of the name and address of such entities for the health plan service provider itself.
Reinforces the new emphasis on ownership transparency by ensuring that contractual agreements cannot be used to hide these relationships from group health plans, thereby empowering plans to better understand their service providers.
Adds a clarification that the civil enforcement authority for group health plan access to information (up to $10,000/day penalty) shall not be construed to permit the Secretary to regulate health care providers acting in their capacity as medical organizations furnishing items and services to patients.
This carves out a specific limitation on the Secretary's enforcement power, ensuring that the new data access requirements for plans do not inadvertently lead to direct regulation of medical practice.
This new section establishes comprehensive oversight requirements for administrative service providers (including health insurance issuers acting as TPAs, PBMs, etc.) for specified large employer plans or specified large plans. It mandates quarterly disclosure of detailed contractual methodologies, fee schedules, rebates, discounts, and payment data for alternative compensation arrangements to group health plans or health insurance issuers. It also includes ownership disclosure for providers filing claims under the plan and for the health plan service provider itself.
This is a major new regulatory framework, consolidating and expanding the data access and transparency requirements for third-party administrators and other service providers, moving them from ERISA to PHSA and adding significant detail and enforcement. It aims to give large plans unprecedented insight into the financial dealings of their service providers.
Adds a notification to the Advanced Explanation of Benefits (AEOB) that the recipient may be held harmless if the AEOB does not match the billed amount. It then establishes a "hold harmless" provision, stating that a participant, beneficiary, or enrollee shall not be held responsible for amounts substantially in excess of the AEOB estimate, with an exception for medically necessary unforeseen circumstances.
This is a crucial new patient protection, shifting financial risk away from patients when AEOB estimates are inaccurate, thereby enhancing the reliability and utility of price transparency tools.
Adds a "hold harmless" provision for patients when the final charges for items and services are substantially in excess of the good faith estimate (GFE) provided to the plan or coverage, meaning the provider cannot bill the patient for these excess amounts. An exception is made for medically necessary unforeseen circumstances.
This directly addresses discrepancies between initial estimates and final bills, protecting patients from unexpected charges and placing the burden of accurate estimation on providers.
Adds requirements for the Explanation of Benefits (EOB) to include the contracted rate under the plan/coverage, the charges submitted by the provider/facility, and information pertaining to the plan type.
Provides patients with more comprehensive financial details on their EOBs, facilitating a better understanding of how their costs are determined and allowing for easier comparison with disclosed rates.
Amends the HITECH Act to explicitly require covered entities or business associates to provide an itemized copy of a bill for services within 30 days of request, without imposing a fee, and to include specific content (plain language description, billing codes, price/billed amount).
This codifies a patient's right to a detailed, free, and timely itemized bill under existing health information technology law, strengthening patient access to billing information.
Authorizes appropriations for the Secretary of Labor and the Secretary of Health and Human Services for fiscal year 2026 and subsequent years to carry out and enforce the Act and its amendments.
Provides dedicated funding for the implementation and enforcement of the new and expanded transparency requirements, addressing a common challenge in regulatory effectiveness.
Deletions
This entire section in v1 detailed hospital price transparency requirements by amending an existing PHSA subsection. It included specific disclosure mandates, definitions, enforcement penalties, and a strict "no waiver" clause for penalties.
The deletion of this direct amendment means that hospital price transparency is now governed by the new PHSA Section 2718A, which fundamentally restructures the requirements, introduces ownership transparency, and modifies enforcement, including a limited waiver authority. This represents a complete shift in the legislative approach to hospital transparency.
This section in v1 added specific price transparency requirements for clinical diagnostic laboratories as a new subsection to PHSA 2718. It outlined disclosure content, update frequency, and enforcement.
The deletion means laboratory price transparency is now governed by the new PHSA Section 2718A(c), which integrates it into a broader provider transparency framework, changes update frequency, adds ownership disclosure, and modifies enforcement.
This section in v1 added specific price transparency requirements for imaging services as a new subsection to PHSA 2718. It outlined disclosure content, update frequency, and enforcement.
The deletion means imaging services transparency is now governed by the new PHSA Section 2718A(d), which integrates it into a broader provider transparency framework, changes update frequency, adds ownership disclosure, and modifies enforcement.
This section in v1 added specific price transparency requirements for ambulatory surgical centers (ASCs) as a new subsection to PHSA 2718. It outlined disclosure content, update frequency, and enforcement.
The deletion means ASC transparency is now governed by the new PHSA Section 2718A(e), which integrates it into a broader provider transparency framework, changes update frequency, adds ownership disclosure, and modifies enforcement.
This section in v1 amended the ACA to strengthen health coverage transparency requirements, particularly regarding self-service tools and the disclosure of rate and payment information by health plans. It included specific audit requirements for HHS and Labor.
The deletion means health coverage transparency is now governed by the new PHSA Section 2715A(b), which is a different statutory basis and includes new requirements like ownership disclosure for plans, proactive information at enrollment, and revised audit mandates.
This section in v1 amended ERISA to require contracts with Covered Service Providers to allow group health plans access to health data, claims information, and pricing terms.
While the concept of group health plan access to data is retained, its statutory basis and specific requirements are moved to PHSA Section 2799A-9(l) in v2, and it is limited to "specified large employer" or "specified large plan." This represents a shift in the legal framework and scope of applicability.
This section in v1 updated the attestation requirements for gag clauses under ERISA, including a limitation on plans entering agreements with TPAs to submit attestations.
The attestation requirement is moved to PHSA Section 2799A-9(a)(4) in v2, and the specific "limitation on submission" clause (prohibiting plans from having TPAs submit attestations) is removed. This changes the regulatory approach to attestation.
This section in v1 added a new ERISA section for the oversight of administrative service providers, requiring quarterly disclosures of contractual methodologies, rebates, and payment data to group health plans.
This entire ERISA section is deleted. Its content is replaced and expanded by the new PHSA Section 2799A-12 in v2, which consolidates oversight under PHSA and applies to "specified large" plans/employers, and allows for an opt-in for health insurance issuers.
This section in v1 added a new PHSA section for the oversight of administrative service providers for self-funded, non-Federal governmental plans, mirroring the ERISA 726 provisions.
This entire PHSA section is deleted. Its content is replaced and expanded by the new PHSA Section 2799A-12 in v2, which consolidates oversight under PHSA and applies to "specified large" plans/employers, and allows for an opt-in for health insurance issuers.
This section in v1 made parallel amendments to the Internal Revenue Code to update good faith estimates for emergency services and require explanations of benefits.
These IRC amendments are deleted. The requirements for EOBs and AEOBs are now solely under the PHSA in v2, removing the parallel enforcement mechanism under the tax code.
This section in v1 made parallel amendments to ERISA to update good faith estimates for emergency services and require explanations of benefits.
These ERISA amendments are deleted. The requirements for EOBs and AEOBs are now solely under the PHSA in v2, removing the parallel enforcement mechanism under ERISA.
This section in v1 directly mandated health care providers to include a written, itemized bill with any payment request to an individual, specifying its content and prohibiting collection actions for non-compliance or over-billing.
The direct mandate on providers to include an itemized bill is removed. Instead, v2's Section 11 (new PHSA 2799B-10) focuses on a notice of the right to request an itemized bill, and then amends the HITECH Act to create the patient's right to receive such a bill upon request. This shifts the primary legal obligation from a proactive provider duty to a patient's right to request under a different statute.
Modifications
Hospitals will have a slightly reduced administrative burden for updating their price transparency data, potentially leading to less up-to-the-minute information for consumers, but still frequent updates.
Before
Required hospitals to compile and make public standard charges monthly in machine-readable and consumer-friendly formats, including 300 shoppable services initially, then all.
After
Requires hospitals to compile and make public standard charges quarterly (if changes occurred) in machine-readable and consumer-friendly formats. The requirement for 300 shoppable services, then all, is retained.
Hospitals will need to ensure their disclosures align with the specified code sets, potentially requiring adjustments if they heavily relied on CPT for certain disclosures previously. The impact on consumers is likely minimal as long as "other applicable identifiers" covers necessary codes.
Before
Defined standard charges to include a plain language description of each item/service, accompanied by any applicable billing codes, including modifiers, using commonly recognized billing code sets (CPT, HCPCS, DRG, NDC).
After
Retains the plain language description and billing codes, but specifies the billing code sets as Diagnosis Related Group (DRG), Healthcare Common Procedure Coding System (HCPCS) code, National Drug Code (NDC), and other applicable identifiers, removing CPT from the explicit list for hospitals.
Patients will gain greater transparency into these often-hidden costs, allowing for more accurate price comparisons and potentially avoiding unexpected charges. Hospitals will need to ensure these specific fees are clearly disclosed.
Before
Did not explicitly mention facility fees or add-on charges in the definition of standard charges.
After
Explicitly includes "The amount of any facility fee, as defined by the Secretary, or add-on charges that will be part of the final payment amount, in addition to any information that might help the patient understand when a facility fee or add-on charge may apply and how to avoid such charges."
Provides the Secretary with discretion to avoid penalties that could severely harm hospital operations and patient care, offering a safety valve for hospitals facing extreme circumstances, but potentially reducing the strictness of enforcement in some cases.
Before
Stated "No waiver. The Secretary shall not grant or extend any waiver, delay, tolling, or other mitigation of a civil monetary penalty for violation of this subsection."
After
States "No authority to waive or reduce penalty. The Secretary shall not grant or extend any waiver, delay, tolling, or other mitigation of a civil monetary penalty for failing to comply with the requirements of this subsection except where the Secretary determines that imposing the maximum civil monetary penalty, including penalties for persistent noncompliance, will disrupt hospital operations in a manner that impacts patient care."
Laboratories will have a slightly reduced administrative burden for updating their price transparency data.
Before
Required applicable laboratories to make information publicly available on an internet website, updated monthly.
After
Requires applicable laboratories to compile and make publicly available on an internet website the standard charges quarterly (if changes occurred).
Narrows the scope of modifiers required for disclosure to those with material financial impact, potentially simplifying compliance for labs while still providing relevant information to consumers.
Before
Defined standard charges for labs to include billing codes, including modifiers, using commonly recognized billing code sets (CPT, HCPCS, DRG, NDC).
After
Defines standard charges for labs to include billing codes "(including modifiers that materially change the price for insurers or providers, and that materially change out-of-pocket costs for consumers)" using commonly recognized billing code sets (HCPCS, NDC, or other applicable identifier).
Provides the Secretary with discretion to avoid penalties that could severely harm operations and patient care for these providers, similar to the change for hospitals.
Before
Stated "No waiver" for civil monetary penalties for clinical diagnostic laboratories, imaging services, and ambulatory surgical centers.
After
Introduces a limited exception to the "no waiver" rule for these provider types, allowing the Secretary to waive or mitigate penalties if imposing the maximum penalty would disrupt operations in a manner that impacts patient care.
Imaging service providers will have an increased administrative burden for updating their price transparency data, but consumers will have more current information.
Before
Required applicable imaging service providers to make information publicly available on an internet website, updated annually.
After
Requires applicable imaging service providers to compile and make publicly available on an internet website the standard charges quarterly (if changes occurred).
Ambulatory surgical centers will have an increased administrative burden for updating their price transparency data, but consumers will have more current information.
Before
Required specified ambulatory surgical centers to make information publicly available on an internet website, updated annually.
After
Requires specified ambulatory surgical centers to compile and make publicly available on an internet website the standard charges quarterly (if changes occurred).
Provides greater specificity and consistency in how out-of-network costs are presented to consumers, ensuring alignment with established regulatory definitions.
Before
For out-of-network providers, the self-service tool would show "the maximum allowed dollar amount for such item or service."
After
For out-of-network providers, the self-service tool will show "the out-of-network allowed amount (as such term is defined for purposes of section 147.210(a)(2)(xvii) of title 45, Code of Federal Regulation) for such item or service that the plan or coverage will pay without regard to the amount in clause (iii)."
Provides consumers with a more comprehensive understanding of a plan's utilization management practices, including the likelihood of approval or denial, which can inform their healthcare decisions.
Before
Required disclosure of "Any prior authorization, concurrent review, step therapy, fail first, or similar requirements applicable to coverage of such item or service under such plan."
After
Expands this to include "information regarding utilization management practices and determinations, including aggregate information related to approval and denial rates, associated timelines, and appeals, as determined appropriate by the Secretary."
Patients may no longer be automatically held harmless for inaccurate estimates from self-service tools, potentially increasing their financial risk if the tool provides incorrect information. However, new "hold harmless" provisions are added in Section 10 for AEOBs and GFEs.
Before
The self-service tool was required to "hold a member harmless for the amount of any difference in excess of the amount of the individual's responsibility generated by the self-service tool and the amount ultimately billed or charged to the individual."
After
This "hold harmless" clause for the self-service tool is removed.
Health plans will have a slightly reduced administrative burden for updating their rate and payment data.
Before
Required health plans to make rate and payment information available to the public monthly.
After
Requires health plans to make rate and payment information available to the public quarterly (if changes occurred).
Provides a more flexible, Secretary-defined exclusion criterion for providers, potentially allowing plans to omit more providers from disclosure if they are genuinely unlikely to be reimbursed for a specific service.
Before
Required in-network rates for each item/service, excluding providers that submitted no claims and expected no claims in the calendar year.
After
Required in-network rates for each item/service, excluding providers that an issuer has determined "based on factors determined by the Secretary (such as medical specialty) that it is unlikely that the provider would be reimbursed for the item or service."
Provides consumers with real-time in-network rates for drugs at the point of sale, which is more actionable than historical net prices. However, it removes the disclosure of the plan's actual historical cost after rebates, which could have provided insight into PBM practices.
Before
Required historical net price paid by the plan for drugs (net of rebates/discounts) for a 90-day period beginning 180 days before submission, broken down by provider.
After
Requires the in-network rate (dollar amount or percentage of charges) for each drug/biologic, in effect as of the first day of the quarter, with each pharmacy or other prescription drug dispenser. The historical net price is removed.
Provides the Secretary flexibility in defining the lookback window, potentially improving data relevance. The "fewer than 11 claims" threshold aims to protect the privacy of providers and plans by not disclosing rates for very low-volume services, but it also means some data will be withheld.
Before
Required billed/allowed amounts for out-of-network services furnished during a 90-day period beginning 180 days before submission, excluding items/services with no claims during that period.
After
Required billed/allowed amounts for out-of-network services furnished during a "representative lookback window established by the Secretary," excluding items/services with "not fewer than 11 claims" during that period.
Reduces the direct burden on health plan executives for data compilation, but shifts accountability to their service providers, potentially impacting the rigor of internal oversight if not managed carefully.
Before
Required an officer or executive to attest to the accuracy and completeness of submitted information.
After
Allows a plan or coverage to satisfy the attestation requirement by obtaining such an attestation from a third-party administrator or other service provider if they rely on them to compile the information.
Increases the scope of audits for technical compliance, potentially improving data usability. However, it implicitly shifts the focus of the Secretary's direct audits to technical aspects, while v1's audit also covered the content of the files.
Before
Required the Secretary to audit the three machine-readable files posted by no fewer than 20 group health plans or health insurance issuers.
After
Requires the Secretary to audit the machine-readable files posted by not fewer than 50 group health plans or health insurance issuers for compliance with format and accessibility standards.
Increases the oversight of technical compliance by the Department of Labor and ensures a coordinated, public report on enforcement activities across relevant agencies.
Before
Required regulations to provide that the Secretary of Labor audit no fewer than 200 group health plans or service providers for machine-readable files, and that findings be reported annually to Congress.
After
Requires regulations to provide that the Secretary of Labor annually audit no fewer than 250 group health plans or service providers for compliance with format and accessibility standards. It also mandates a joint annual report to Congress from HHS, Labor, and Treasury on audit findings, conclusions, and enforcement actions.
Smaller employers and plans will not be subject to these new data access mandates, potentially reducing their ability to obtain detailed information from their service providers.
Before
Required contracts with Covered Service Providers to allow group health plans access to data, without specific limitations on plan size.
After
Limits the applicability of the group health plan access to information requirements to group health plans "offered by a specified large employer or that is a specified large plan."
Ensures that while plans gain access to more data, individually identifiable health information remains protected, balancing transparency with patient privacy.
Before
Required Covered Service Providers to provide information consistent with HIPAA privacy and security regulations.
After
Clarifies that Covered Service Providers shall not be required to disclose information or data under this subsection that "could reasonably identify a participant or beneficiary through individually identifiable health information."
Ensures compliance with the most current industry standards for dental claims, potentially improving data interoperability and accuracy for these claims.
Before
Required institutional, professional, and dental claims to be in ASC X12N 837 format.
After
Specifies institutional, professional, and dental claims to be in "ASC X12N 837D format or any subsequent standard as established by the Secretary."
Allows plans to rely on their third-party administrators to submit the gag clause attestations, potentially reducing administrative burden on plans but shifting direct responsibility.
Before
Stated "Limitation on submission. Subject to clause (ii), a group health plan or issuer offering group health insurance coverage may not enter into an agreement with a third-party administrator or other service provider to submit the attestation required under subparagraph (A)."
After
This "Limitation on submission" clause is removed.
Smaller plans and employers are no longer mandatorily covered by these oversight requirements, potentially reducing their access to detailed service provider data. Health insurance issuers gain the flexibility to opt into these requirements.
Before
Applied oversight requirements for administrative service providers to group health plans (ERISA 726) and self-funded, non-Federal governmental plans (PHSA 2799A-11).
After
Consolidates these requirements under a single new PHSA section 2799A-12, applying them to group health plans "offered by a specified large employer or that is a specified large plan." It also allows health insurance issuers offering individual or group health coverage to elect to require a report.
Provides greater clarity and potentially more realistic timelines for plans/issuers to issue EOBs, as the clock starts when they have all the information needed to process the claim.
Before
Required an Explanation of Benefits (EOB) within 45 days of "receiving any request for payment" for an item or service.
After
Requires an EOB within 45 days of "receiving the information necessary to decide a claim for payment (as defined by the Secretary) for an item or service under the plan or coverage for which liability under the plan or coverage has been determined."
Provides patients with more useful contextual information about where services were rendered, which can impact cost and understanding of the bill.
Before
Required the EOB to include "The site of each item or service."
After
Requires the EOB to include "The type of site of each item or service, including office, facility, or emergency room."
Enhances patient understanding of their bills by explicitly pointing out differences from prior estimates and clarifying the nature of facility fees, supporting the new "hold harmless" provisions.
Before
Did not explicitly require EOBs to include discrepancies with AEOBs or facility fees.
After
Adds requirements for the EOB to include "If applicable, a description of any discrepancies that exist between the services outlined in a patient's advanced explanation of benefits and the explanation of benefits" and "The amount of any facility fee or other patient charges that were added to the final payment amount, together with a plain language explanation of the fee, if applicable."
Changes the mechanism by which patients receive itemized bills. While patients still have a right to an itemized bill, they must now actively request it, rather than receiving it automatically with a payment request. This could place a greater burden on patients to know and exercise their rights.
Before
Required a health care provider/facility to include a written, itemized bill with any payment request to an individual.
After
Requires a health care provider/facility to include with any payment request a written notice of the individual's right to request an itemized bill as part of their designated record set under HIPAA regulations.
The information provided proactively with a payment request is now a notice of rights, rather than the detailed bill itself.
Before
Specified detailed content for the itemized bill itself (plain language, billing codes, price, payments made, language assistance, contact, charity care).
After
Specifies content for the notice of the right to request an itemized bill (phone/website for request, language assistance, charity care). The detailed content of the itemized bill is now specified in the HITECH Act amendment.
Scope
Complete substitute — Changes are scattered throughout the bill, affecting nearly every section and fundamentally altering the legislative approach to price transparency and data access. — v2 represents a meaningful change in policy direction, shifting from amending existing specific sections to creating new, consolidated frameworks within the Public Health Service Act. It significantly expands ownership transparency and introduces new patient protections regarding billing discrepancies and collection actions. — The changes extensively interact with existing provisions by moving requirements from various acts (ERISA, ACA) into new, consolidated sections of the Public Health Service Act. This re-bases many transparency and data access mandates, impacting how they are enforced and applied. The introduction of new "hold harmless" provisions directly interacts with existing billing and payment processes.
Impact analysis
Hospitals, clinical diagnostic laboratories, imaging service providers, and ambulatory surgical centers
Procedural change (new disclosure requirements, consolidated framework), increased compliance burden (ownership disclosure, increased update frequency for some), and increased risk for non-compliance (collection action prohibition for hospitals). The limited waiver authority provides a potential benefit in extreme circumstances.
These providers are now subject to consolidated price transparency requirements under a new PHSA section (2718A) and are explicitly required to disclose ownership and investment interests. The frequency of updates for some (imaging, ASCs) increased from annually to quarterly, while for others (hospitals, labs) it changed from monthly to quarterly. Enforcement penalties now include a limited waiver authority for the Secretary if maximum penalties disrupt patient care, and hospitals are prohibited from extraordinary collection actions during non-compliance.
Patients/consumers
Gain significant financial protections and greater transparency in billing, but experience a procedural change in how they obtain itemized bills.
Gain new protections against extraordinary collection actions by non-compliant hospitals. Benefit from new "hold harmless" provisions if billed amounts substantially exceed Advanced Explanations of Benefits (AEOBs) or Good Faith Estimates (GFEs). Will receive more detailed EOBs, including discrepancies with AEOBs and facility fees. Have a codified right under HITECH to request a free, itemized bill within 30 days. However, they will now receive a notice of right to request an itemized bill with payment requests, rather than the bill itself.
Group health plans and health insurance issuers
Increased compliance burden (ownership disclosure, proactive enrollment info), procedural changes (attestation delegation, audit focus), and a shift in the type of drug price data disclosed.
Subject to new ownership disclosure requirements. Must provide specific cost information proactively at enrollment. The frequency of public rate/payment information updates changed from monthly to quarterly. Drug price transparency shifts from historical net prices to current in-network rates with pharmacies. Audits by the Secretary of Labor increased in number and focus on technical standards. The attestation for gag clauses can now be delegated to TPAs.
Third-party administrators (TPAs), pharmacy benefit managers (PBMs), and other health plan service providers
Increased compliance burden and procedural changes in data sharing, leading to greater financial transparency for their client plans.
Subject to comprehensive oversight requirements under a new PHSA section (2799A-12), which mandates quarterly disclosure of detailed contractual methodologies, rebates, and payment data for alternative compensation arrangements to "specified large" group health plans. Also subject to new ownership disclosure requirements.
Small employers and small group health plans
Lose the mandatory right to access detailed data from their service providers that larger plans will have, potentially leaving them with less negotiating power and transparency.
The group health plan access to health data (Section 7) and oversight of administrative service providers (Section 8) provisions are now limited to "specified large employer" or "specified large plan."
Federal agencies (HHS, Labor, Treasury)
Gain resources and clarified authority, but also increased reporting obligations.
Receive explicit appropriations authorization for implementation and enforcement. HHS gains limited discretion to waive penalties for providers in certain circumstances. HHS, Labor, and Treasury are mandated to issue a joint annual report to Congress on audit findings.