(1)

in paragraph (1), by striking the sum of and all that follows through the period and inserting an amount equal to the applicable dollar amount under paragraph (1)(B) of section 402(g) (as adjusted pursuant to paragraph (4) of such section) with respect to such taxable year.,

(2)

by striking paragraphs (2), (3), (5), (7), and (8),

(3)

by inserting after paragraph (1) the following:

(2) Additional contributions for individuals 50 or older

In the case of an individual who has attained age 50 before the close of the taxable year, the amount of the limitation under paragraph (1) shall be increased by an amount equal to the applicable dollar amount under subparagraph (B)(i) of section 414(v)(2) (as adjusted pursuant to subparagraph (C) of such section).,

(4)

in paragraph (4), by striking the flush matter following subparagraph (C), and

(5)

by redesignating paragraphs (4) and (6) as paragraphs (3) and (4), respectively.

(1)

Subparagraph (A) of section 223(d)(1) of the Internal Revenue Code of 1986 is amended by striking the sum of— and all that follows through the period and inserting the amount determined under subsection (b)(1)..

(2)

Subsection (g)(1) of section 223 of such Code is amended—

(3)

Section 26(b)(2)(S) of such Code is amended by striking , 223(b)(8)(B)(i)(II),.

(4)

Section 408(d)(9)(C)(i)(I) of such Code is amended by striking computed on the basis of the type of coverage under the high deductible health plan covering the individual.

(1)

Subsection (a) of section 223 of the Internal Revenue Code of 1986 is amended to read as follows:

(a) Deduction allowed

In the case of an individual, there shall be allowed as a deduction for the taxable year an amount equal to the aggregate amount paid in cash during such taxable year by or on behalf of such individual to a health savings account of such individual.

(2)

Subsection (c)(1)(A) of section 223 of such Code, as amended by section 102 and redesignated by subsection (a), is further amended by striking subsection (f)(4) and inserting subsection (e)(4).

(3)

Subparagraph (U) of section 26(b)(2) of such Code, as amended by section 102, is further amended by striking section 223(f)(4) and inserting section 223(e)(4).

(4)

Sections 35(g)(3), 220(f)(5)(A), 848(e)(1)(B)(v), 4973(a)(5), and 6051(a)(12) of such Code are each amended by striking section 223(d) each place it appears and inserting section 223(c).

(5)

Section 106(d)(1) of such Code is amended—

(6)

Section 106(e) of such Code is amended—

(7)

Section 408(d)(9)(A) of such Code is amended by striking who is an eligible individual (as defined in section 223(c)) and.

(8)

Section 877A(g)(6) of such Code is amended by striking 223(f)(4) and inserting 223(e)(4).

(9)

Section 4973(g) of such Code is amended—

(10)

Section 4975 of such Code is amended—

(11)

Subsection (b) of section 4980G of such Code is amended to read as follows:

(b) Rules and requirements

(1) In general

An employer meets the requirements of this subsection for any calendar year if the employer makes available comparable contributions to the health savings accounts of all comparable participating employees for each coverage period during such calendar year.

(2) Comparable contributions

(A) In general

For purposes of paragraph (1), the term comparable contributions means contributions—

(i)

which are the same amount, or

(ii)

if the employees are covered by a health plan, which are the same percentage of the annual deductible limit under the plan covering the employees.

(B) Part-year employees

In the case of an employee who is employed by the employer for only a portion of the calendar year, a contribution to the health savings account of such employee shall be treated as comparable if it is an amount which bears the same ratio to the comparable amount (determined without regard to this subparagraph) as such portion bears to the entire calendar year.

(3) Comparable participating employees

For purposes of paragraph (1), the term comparable participating employees means all employees who are covered (if at all) under the same health plan of the employer and have the same category of coverage. For purposes of the preceding sentence, the categories of coverage are self-only and family coverage.

(4) Part-time employees

(A) In general

Paragraph (3) shall be applied separately with respect to part-time employees and other employees.

(B) Part-time employee

For purposes of subparagraph (A), the term part-time employee means any employee who is customarily employed for fewer than 30 hours per week.

(12)

Section 4980G(d) of such Code is amended by striking section 4980E and inserting this section.

(13)

Section 6693(a)(2)(C) of such Code is amended by striking section 223(h) and inserting section 223(f).

(1)

in subparagraph (A), by inserting or pursuant to an arrangement under which an individual is provided coverage restricted to primary care services in exchange for a fixed periodic fee or payment for primary care services after menstrual care products,

(2)

by striking subparagraphs (B) and (C), and

(3)

by redesignating subparagraph (D) as subparagraph (B).

(1)

Section 220(d)(2)(A) of the Internal Revenue Code of 1986 is amended by striking section 223(d)(2)(D) and inserting section 223(c)(2)(B).

(2)

Subsection (f) of section 106 of the Internal Revenue Code of 1986 is amended by striking section 223(d)(2)(D) and inserting section 223(c)(2)(B).

(1) In general

The amendments made by subsections (a) and (b) shall apply with respect to amounts paid after the date of the enactment of this Act in taxable years beginning after such date.

(2) Technical amendments

The amendments made by subsection (c) shall apply with respect to taxable years beginning after the date of enactment of this Act.

(1)

by inserting , child, parent, or grandparent after surviving spouse,

(2)

by inserting , child, parent, or grandparent, as the case may be, after the spouse,

(3)

by inserting , child, parent, or grandparent after spouse in the heading thereof, and

(4)

by adding at the end the following: In the case of a child who acquires such beneficiary’s interest and with respect to whom a deduction under section 151 is allowable to another taxpayer for a taxable year beginning in the calendar year in which such individual’s taxable year begins, such health savings account shall be treated as a health savings account of such child..

(1)

in subparagraph (A), by adding at the end the following new sentence: For purposes of this subparagraph, amounts paid for qualified wellness expenses shall be treated as paid for medical care, but only to the extent that such amounts paid with respect to each individual described in the first sentence of this subparagraph do not exceed $100 per month in the case of a health savings account the balance of which does not exceed $5,000; $150 per month in the case of a health savings account the balance of which exceeds $5,000 but does not exceed $10,000; and $200 per month in the case of a health savings account the balance of which exceeds $10,000., and

(2)

by adding at the end the following:

(D) Qualified wellness expenses

(i) In general

For purposes of this paragraph, the term qualified wellness expenses means amounts paid for healthy food, vitamins, dietary supplements (as defined in section 201(ff) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 321(ff))), or qualified sports and fitness expenses.

(ii) Healthy food

The term healthy food means any individual food which meets the criteria of section 101.65(d)(3)(i) of title 21, Code of Federal Regulations (or any successor regulations).

(iii) Qualified sports and fitness expenses

(I) In general

The term qualified sports and fitness expenses means amounts paid exclusively for the sole purpose of participating in a physical activity, including—

(aa)

for membership at a fitness facility,

(bb)

for participation or instruction in physical exercise or physical activity, or

(cc)

for equipment used in a program (including a self-directed program) of physical exercise or physical activity, including a wearable fitness tracker.

(II) Fitness facility

For purposes of subclause (I)(aa), the term fitness facility means a facility—

(aa)

which provides instruction in a program of physical exercise, offers facilities for the preservation, maintenance, encouragement, or development of physical fitness, or serves as the site of such a program of a State or local government or an organization described in section 501(c)(3) and exempt from tax under section 501(a),

(bb)

which is not a private club owned and operated by its members,

(cc)

which does not offer golf, hunting, sailing, or riding facilities,

(dd)

the health or fitness component of which is not incidental to its overall function and purpose, and

(ee)

which is fully compliant with the State of jurisdiction and Federal anti-discrimination laws.

(III) Treatment of exercise videos, etc

Videos, books, and similar materials shall be treated as described in subclause (I)(bb) if the content of such materials constitutes instruction in a program of physical exercise or physical activity.

(IV) Limitations related to sports and fitness equipment

Amounts paid for equipment described in subclause (I)(cc) shall be treated as qualified sports and fitness expenses only—

(aa)

if such equipment is utilized exclusively for participation in fitness, exercise, sport, or other physical activity, and

(bb)

in the case of amounts paid for apparel or footwear, if such apparel or footwear is of a type that is necessary for, and is not used for any purpose other than, a specific physical activity.

(1)

by redesignating paragraphs (2) and (3) as paragraphs (3) and (4), respectively, and

(2)

by inserting after paragraph (1) the following new paragraph:

(2) Limitation

In the case of an employee whose employer makes a contribution of at least $450 per month to such employee’s health savings account, paragraph (1) shall apply to such a contribution only if such employee is enrolled in health care coverage for such month.

(1)

in subsection (c)(1)(A), by inserting or a qualified general contribution, after section 220(f)(5),, and

(2)

in subsection (e)—

(1) In general

Part III of subchapter B of chapter 1 of such Code is amended by inserting before section 140 the following new section:

139M. Qualified general contributions to health savings accounts

(a) In general

Gross income of an account beneficiary shall not include any qualified general contribution to a health savings account of the account beneficiary.

(b) Definitions

Any term used in this section which is used in section 223 shall have the meaning given such term under section 223.

(2) Clerical amendment

The table of sections for part III of subchapter B of chapter 1 of such Code is amended by inserting before the item relating to section 140 the following new item:

(1)

in clause (ii), by striking or at the end,

(2)

in clause (iii), by striking the period at the end and inserting , or, and

(3)

by adding at the end the following new clause:

(iv)

any qualified Trump account seeding distribution (as defined in section 223(e)(10)(B)).

(1)

by redesignating subparagraph (B) as subparagraph (C),

(2)

by inserting after subparagraph (A) the following new subparagraph:

(B) Treatment of rollover to Trump account

(i) In general

If, by reason of the death of the account beneficiary, the entire balance of a health savings account of the account beneficiary is paid or distributed in a direct trustee-to-trustee transfer from such health savings account to a Trump account maintained for the benefit of any eligible individual, the amount so paid or distributed shall not be includible in the gross income of either the account beneficiary or the eligible individual.

(ii) Definitions

For purposes of this subparagraph, the terms Trump account and eligible individual have the meaning given such terms in section 530A(b)., and

(3)

by striking subparagraph (A) does not apply in subparagraph (C), as so redesignated, and inserting subparagraphs (A) and (B) do not apply.

(1)

in clause (iii), by striking or at the end,

(2)

in clause (iv), by strike the period at the end and inserting , or, and

(3)

by adding at the end the following new clause:

(v)

any amount contributed as described in section 223(e)(8)(B).

(A)

in subparagraph (A), by striking subparagraph (B) and inserting subparagraphs (B) and (C); and

(B)

by adding at the end the following:

(C)

With respect to a person that is a member of an entity (referred to in section 736 and this subparagraph as a health marketplace pool) that meets the requirements of section 736(b) and offers a group health plan (as defined in section 733(a)(1)) or group health insurance coverage (as defined in section 733(b)(4)) (which, notwithstanding any other provision of law, may include such a plan or coverage covering prescription or nonprescription drugs as the only benefit offered by the plan or coverage), membership in the health marketplace pool shall not by itself cause the person to be a fiduciary with respect to the group health plan or group health insurance coverage.; and

(A)

in clause (ii), by striking , or and inserting ,;

(B)

in clause (iii), by striking the period and inserting , or; and

(C)

by adding at the end the following:

(iv)

as a group health plan (as defined in section 733(a)(1)), or group health insurance coverage (as defined in section 733(b)(4)), offered by an entity meeting the requirements under section 736(b) (which, notwithstanding any other provision of law, may include such an entity offering such a plan or coverage covering prescription or nonprescription drugs as the only benefit offered by the plan or coverage).

(1) In general

The amendment made by subsection (a) shall apply beginning January 1, 2027.

(2) Continued applicability of rules for previous years

Nothing in the amendment made by this section may be construed as affecting the applicability of the regulations codified at part 180 of title 45, Code of Federal Regulations, before January 1, 2026.

(1)

by striking The Exchange and inserting the following:

(i) In general

The Exchange;

(2)

in clause (i), as inserted by paragraph (1)—

(3)

by adding at the end the following new clauses:

(ii) Specified information

For purposes of clause (i), the information specified in this clause is, with respect to benefits available under a health plan for an item or service furnished by a health care provider, the following:

(I)

If such provider is a participating provider with respect to such item or service, the in-network rate (as defined in subparagraph (F)) for such item or service.

(II)

If such provider is not described in subclause (I), the maximum allowed dollar amount for such item or service.

(III)

The amount of cost sharing (including deductibles, copayments, and coinsurance) that the individual will incur for such item or service (which, in the case such item or service is to be furnished by a provider described in subclause (II), shall be calculated using the maximum amount described in such subclause).

(IV)

The amount the individual has already accumulated with respect to any deductible or out of pocket maximum under the plan (broken down, in the case separate deductibles or maximums apply to separate individuals enrolled in the plan, by such separate deductibles or maximums, in addition to any cumulative deductible or maximum).

(V)

In the case such plan imposes any frequency or volume limitations with respect to such item or service (excluding medical necessity determinations), the amount that such individual has accrued towards such limitation with respect to such item or service.

(VI)

Any prior authorization, concurrent review, step therapy, fail first, or similar requirements applicable to coverage of such item or service under such plan.

(iii) Self-service tool

For purposes of clause (i), a self-service tool established by a health plan meets the requirements of this clause if such tool—

(I)

is based on an internet website;

(II)

provides for real-time responses to requests described in such clause;

(III)

is updated in a manner such that information provided through such tool is timely and accurate;

(IV)

allows such a request to be made with respect to an item or service furnished by—

(aa)

a specific provider that is a participating provider with respect to such item or service;

(bb)

all providers that are participating providers with respect to such plan and such item or service; or

(cc)

a provider that is not described in item (bb);

(V)

provides that such a request may be made with respect to an item or service through use of—

(aa)

the billing code for such item or service; or

(bb)

through use of a descriptive term for such item or service to produce a list of billing code options from which the individual selects to indicate the subject matter items or services; and

(VI)

holds 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.

(1) In general

The amendments made by subsections (a) and (b) shall apply beginning January 1, 2027.

(2) Continued applicability of rules for previous years

Nothing in the amendments made by this section may be construed as affecting the applicability of the rule entitled Transparency in Coverage published by the Department of the Treasury, the Department of Labor, and the Department of Health and Human Services on November 12, 2020 (85 Fed. Reg. 72158), before January 1, 2027.

(1) In general

Paragraph (2) of section 408(b) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1108(b)) is amended by adding at the end the following new subparagraphs:

(C)

No contract or arrangement for services, and no extension or renewal of such contract or arrangement, between a group health plan (as that term is defined in section 733(a) of this title) and party in interest, including a health care provider (which for purposes of this subparagraph, includes a health care facility), network or association of providers, service provider offering access to a network of providers, or third-party administrator (collectively referred to as Covered Service Providers), is reasonable within the meaning of this paragraph unless such contract or arrangement—

(i)

allows the responsible plan fiduciary (as that term is defined in subparagraph (B)(ii)(I)(ee)) access to all claims and encounter information or data, and any documentation supporting claim payments, including, but not limited to, medical records and policy documents, or information or data described in section 724(a)(1)(B) to—

(I)

enable such entity to comply with the terms of the plan and any applicable law; and

(II)

determine the accuracy or reasonableness of payment; and

(ii)

does not—

(I)

unreasonably limit or delay access, as determined by the Secretary but in any event not longer than 15 days, to such information or data;

(II)

limit the volume of claims and encounter information or data that the group health plan, the plan sponsor, the plan administrator, or a business associate of such plan may access during an audit or pursuant to any request for such information or data;

(III)

limit the disclosure of pricing terms for value-based payment arrangements or capitated payment arrangements, including—

(aa)

payment calculations and formulas;

(bb)

quality measures;

(cc)

contract terms;

(dd)

payment amounts;

(ee)

measurement periods for all incentives; and

(ff)

other payment methodologies used by an entity, including a health care provider (including a health care facility), network or association of providers, service provider offering access to a network of providers, or third-party administrator;

(IV)

limit the disclosure of overpayments and overpayment recovery terms;

(V)

limit the right of the group health plan, the plan sponsor, or the plan administrator of such plan to select an auditor or define audit scope or frequency;

(VI)

otherwise limit or unduly delay the group health plan, the plan sponsor, the plan administrator, or a business associate of such plan from accessing claims and encounter information or data in a daily batch;

(VII)

limit the disclosure of fees charged to the group health plan related to plan administration and claims processing, including renegotiation fees, access fees, repricing fees, or enhanced review fees;

(VIII)

limit the right of the group health plan, the plan sponsor, or the plan administrator to request action on any suspect claim payments; or

(IX)

limit public disclosure of de-identified or aggregate information.

(D)

(i)

Covered Service Providers shall provide information or data under this paragraph in a manner consistent with the privacy and security regulations promulgated under the Health Insurance Portability and Accountability Act (referred to in this subparagraph as HIPAA).

(ii)

A group health plan that receives a disclosure from a party in interest pursuant to subparagraph (B) or (C) shall comply with the privacy and security regulations promulgated under HIPAA.

(iii)

Nothing in this subparagraph shall be construed to modify the requirements for the creation, receipt, maintenance, or transmission of protected health information under the HIPAA privacy regulation (as defined in section 1180(b)(3) of the Social Security Act) as they apply directly or indirectly to an entity pursuant to this paragraph.

(iv)

This subparagraph shall not be read to abridge or limit the disclosure requirements under this paragraph or to impose additional privacy or security requirements on Covered Service Providers or plan sponsors.

(E)

A group health plan receiving information or data under this paragraph may disclose such information only in a manner that is consistent with the Health Insurance Portability and Accountability Act (HIPAA) and the privacy and security regulations promulgated thereunder, regardless of their direct or indirect applicability to the plan or any entities that could be or are business associates.

(F)

Information made available under this section shall conform to the following standards:

(i)

All claims from a healthcare provider shall be made to the group health plan in accordance with transaction standards adopted by regulation under HIPAA, as follows:

(I)

Institutional, professional, and dental claims shall be in ASC X12N 837 format or any subsequent standard.

(II)

Pharmacy claims shall be in the National Council for Prescription Drug Programs (NCPDP) format or any subsequent standard.

(III)

The files shall be unmodified copies of the files sent from the provider. In the event that paper claims are sent by the provider, they shall be converted to the appropriate standard electronic format. Files shall be accessible to the plan at no cost to the group health plan.

(ii)

All claim payment (or EFT, electronic funds transfer) and electronic remittance advice (ERA) notices sent by a Covered Service Provider shall be made available to the group health plan as ASC X12N 835 files in accordance with standards adopted by regulation under HIPAA. The files shall be unmodified copies of the files sent by the Covered Service Provider to the healthcare provider. Files shall be accessible at no cost to the group health plan.

(iii)

The contractual terms containing calculation formulae, pricing methodologies, and other information used to determine the dollar value of reimbursement.

(iv)

All non-claim costs shall be itemized and made available to the group health plan in real time through a web-based portal, through an API, and through a downloadable CSV file.

(G)

The Secretary shall implement subparagraphs (C) through (F) through notice and comment rulemaking in accordance with section 553 of title 5, United States Code.

(2) Civil enforcement

Subsection (c) of section 502 of such Act (29 U.S.C. 1132) is amended by adding at the end the following new paragraph:

(13)

In the case of an agreement between a group health plan (as defined in section 733(a)), the plan sponsor of such plan (as defined in section 3(16)(B)), or the plan administrator of such plan (as defined in section 3(16)(A)) and a health care provider (which, for purposes of this paragraph, includes a health care facility), network or association of providers, service provider offering access to a network or association of providers, or third-party administrator, that violates the provisions of section 724, the Secretary may assess a civil penalty against such provider, network or association, service provider offering access to a network or association of providers, third-party administrator, or other service provider in the amount of $10,000 for each day during which such violation continues. Such penalty shall be in addition to other penalties as may be prescribed by law.

(3) Existing provisions void

Section 410 of such Act (29 U.S.C. 1110) is amended by adding at the end the following:

(c)

Any provision in an agreement or instrument shall be void as against public policy if such provision—

(1)

unduly delays or limits a group health plan (as defined in section 733(a)), the plan sponsor of such plan (as defined in section 3(16)(B)), or the plan administrator of such plan (as defined in section 3(16)(A)) from accessing the claims and encounter information or data described in section 724(a)(1)(B); or

(2)

violates the requirements of section 408(b)(2)(C).

(4) Technical amendment

Clause (i) of section 408(b)(2)(B) of such Act is amended by striking this clause and inserting this paragraph.

(1) In general

Subpart B of part 7 of subtitle B of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1021 et seq.) is amended by adding at the end the following:

727. Oversight of administrative service providers

(a) In general

For plan years beginning on or after the date that is 2 years after the date of enactment of this section, no agreement between a group health plan (as defined in section 733(a)), the plan sponsor of such plan (as defined in section 3(16)(B)), the plan administrator of such plan (as defined in section 3(16)(A)), or a business associate of such plan (as defined in section 160.103 of title 45, Code of Federal Regulations), (or health insurance issuer offering group health insurance coverage in connection with such a plan), and a health care provider, network or association of providers, third-party administrator, service provider offering access to a network of providers, or any other third party (each referred to as a health plan service provider) is permissible if such agreement limits (or delays beyond the applicable reporting period described in subsection (b)(1)) the disclosure of information to group health plans in such a manner that prevents such plan, issuer, or entity from providing the information described in subsection (b).

(b) Required disclosures

(1) Contents and frequency

With respect to plan years beginning on or after the date that is 2 years after the date of enactment of this section, not less frequently than quarterly, a health plan service provider shall provide to the group health plan or health insurance issuer the following information at no cost to the group health plan or health insurance issuer:

(A)

The information described in section 724(a)(1)(B).

(B)

Any contractual and subcontractual calculation methodologies, pricing or fee schedules, or other formulae used to determine reimbursement amounts to providers and subcontractors, including methodologies, schedules, fee structures, and any applied adjustments or modifiers, with such information provided in a manner sufficiently detailed to enable the group health plan or health insurance issuer to accurately assess, verify, and ensure compliance with the terms of any contractual and subcontractual agreement governing the reimbursement amounts.

(C)

The total amount received or expected to be received by the health plan service provider or its subcontractors in provider or supplier rebates, fees, alternative discounts, and all other remuneration including amounts held in escrow or variance accounts that has been paid or is to be paid for claims incurred and administrative services including data sales or network payments.

(D)

The total amount paid or expected to be paid by the health plan service provider or to subcontractors in rebates, fees, contractual arrangements, and all other remuneration that has been paid or is expected to be paid for administrative and other services.

(E)

All payment data and reconciliation information related to alternative compensation arrangements including accountable care organizations, value-based programs, shared savings programs, incentive compensation, bundled payments, capitation arrangements, performance payments, and any other reimbursement or payment models, where the group health plan or health insurance issuer paid fees, incurred obligations, or made payments in connection with the group health plan related to such arrangements.

(2) Privacy requirements

(A) In general

Health plan service providers shall provide the information or data under paragraph (1) consistent with the privacy, security, and breach notification regulations at parts 160 and 164 of title 45, Code of Federal Regulations, promulgated under subtitle F of the Health Insurance Portability and Accountability Act of 1996, subtitle D of the Health Information Technology for Clinical Health Act of 2009, and section 1180 of the Social Security Act, and shall restrict the use and disclosure of such information according to such privacy, security, and breach notification regulations. An entity that receives a disclosure from a party in interest pursuant to subparagraph (B) or (C) shall comply with the privacy and security regulations promulgated under HIPAA.

(B) Restrictions

A group health plan shall comply with section 164.504(f) of title 45, Code of Federal Regulations (or a successor regulation), and a plan sponsor shall act in accordance with the terms of the agreement described in such section.

(C) Rule of construction

Nothing in this section shall be construed to modify the requirements for the creation, receipt, maintenance, or transmission of protected health information under the HIPAA privacy regulations (45 C.F.R. parts 160 and 164, subparts A and E).

(3) Disclosure and redisclosure

(A) In general

A group health plan receiving information under paragraph (1) may disclose such information only—

(i)

to the entity from which the information was received or to that entity’s business associates or to the group health plan's business associates as defined in section 160.103 of title 45, Code of Federal Regulations (or successor regulations); or

(ii)

as permitted by the HIPAA Privacy Rule (45 C.F.R. parts 160 and 164, subparts A and E).

(B) Availability of information

To the extent the information required by this subsection is made available to the health insurance issuer offering group health insurance in connection with a group health plan, the health insurance issuer shall make such information available, at the same time, in the same format, and at no cost, to the group health plan.

(C) Failure to provide

The obligation to provide information pursuant to this subsection shall exist notwithstanding the presence of any formal data-sharing agreement between the parties. Failure to provide the required information as specified shall constitute a violation of this Act and the Secretary shall initiate enforcement action under section 502 within 90 days of becoming aware of a violation of this section, except that nothing in this section shall be construed to limit the Secretary's existing authority under the Act.

(4) Data format standards

All data and information provided pursuant to this subsection shall comply with the following standards:

(A)

All claims from a healthcare provider shall be made to the group health plan in accordance with transactions standards adopted under HIPAA, as follows:

(i)

Institutional, professional, and dental claims and adjustments to these claims shall be in ASC X12N 837 format, as transmitted by the provider, or, in the case of paper claims, converted to the ASC X12N 837 electronic format.

(ii)

Prescription drug claims shall be in the National Council for Prescription Drug Programs (NCPDP) format, as transmitted by the provider, or in the case of paper claims, converted to the NCPDP electronic format.

(iii)

Such data shall be provided at no cost to the group health plan.

(B)

All claim payment (or EFT, electronic funds transfer) and electronic remittance advice (ERA) information sent by a health plan service provider shall be provided to the group health plan or health insurance issuer in the ASC X12N 835 format in accordance with transaction standards adopted under HIPAA, unmodified from the form in which it was transmitted to the healthcare provider. Such information shall be provided at no cost to the group health plan or health insurance issuer.

(C)

The Secretary may modify the standards set forth in this paragraph as necessary to align with any changes adopted by the Secretary of Health and Human Services pursuant to the authority provided under section 1173 of the Social Security Act (42 U.S.C. 1320d–2).

(c) Prohibited contractual provisions

Any provision in an agreement between a group health plan, the plan sponsor, the plan administrator, or a business associate of such plan or a health insurance issuer and a health plan service provider that unduly delays or limits a group health plan’s or health insurance issuer’s access to information described in this section or that restricts the format or timing of the provision of such information in a manner that is inconsistent with the requirements of this section shall be prohibited and, if a group health plan or health insurance issuer enters into such agreement, shall be deemed void as against public policy.

(d) Penalties for non-Compliance

Any failure by a health plan service provider to comply with the requirements of this section shall result in the imposition of a civil penalty of $100,000 for each day the violation continues, in addition to any other penalties prescribed by law.

(e) Regulations

The Secretary shall implement this section through notice and comment rulemaking in accordance with section 553 of title 5, United States Code.

(2) Penalty

(1) In general

Part D of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–111 et seq.) is amended by adding at the end the following:

2799A–12. Oversight of administrative service providers

(a) In general

For plan years beginning on or after the date that is 1 year after the date of enactment of this section, no agreement between a group health plan that is a self-funded, non-Federal governmental plan, as defined in section 2791(d)(8)(C) (42 U.S.C. 300gg–91(d)(8)(C)), and a health care provider, network or association of providers, third-party administrator, service provider offering access to a network of providers, or any other third party (each referred to in this section as a health plan service provider) is permissible if such agreement limits (or delays beyond the applicable reporting period described in subsection (b)(1)) the disclosure of information to group health plans in such a manner that prevents such plan, issuer, or entity from providing the information described in subsection (b).

(b) Required disclosures

(1) Contents and frequency

With respect to plan years beginning on or after the date that is 1 year after the date of enactment of this section, not less frequently than quarterly, a health plan service provider shall provide to the group health plan that is a self-funded, non-Federal governmental plan the following information at no cost to the plan:

(A)

The information described in section 2799A–9(a)(1)(B) (42 U.S.C. 300gg–119(a)(1)(B)).

(B)

Any contractual and subcontractual calculation methodologies, pricing or fee schedules, or other formulae used to determine reimbursement amounts to providers and subcontractors, including methodologies, schedules, fee structures, and any applied adjustments or modifiers, with such information provided in a manner sufficiently detailed to enable the group health plan to accurately assess, verify, and ensure compliance with the terms of any contractual and subcontractual agreement governing the reimbursement amounts.

(C)

The total amount received or expected to be received by the health plan service provider or its subcontractors in provider or supplier rebates, fees, alternative discounts, and all other remuneration including amounts held in escrow or variance accounts that has been paid or is to be paid for claims incurred and administrative services including data sales or network payments.

(D)

The total amount paid or expected to be paid by the health plan service provider or to subcontractors in rebates, fees, contractual arrangements, and all other remuneration that has been paid or is expected to be paid for administrative and other services.

(E)

All payment data and reconciliation information related to alternative compensation arrangements including accountable care organizations, value-based programs, shared savings programs, incentive compensation, bundled payments, capitation arrangements, performance payments, and any other reimbursement or payment models, where the group health plan paid fees, incurred obligations, or made payments in connection with the group health plan related to such arrangements.

(2) Privacy requirements

(A) In general

Health plan service providers shall provide the information or data under paragraph (1) consistent with the privacy, security, and breach notification regulations at parts 160 and 164 of title 45, Code of Federal Regulations, promulgated under subtitle F of the Health Insurance Portability and Accountability Act of 1996, subtitle D of the Health Information Technology for Clinical Health Act of 2009, and section 1180 of the Social Security Act, and shall restrict the use and disclosure of such information according to such privacy, security, and breach notification regulations. An entity that receives a disclosure from a party in interest pursuant to subparagraph (B) or (C) shall comply with the privacy and security regulations promulgated under HIPAA.

(B) Restrictions

A group health plan that is a self-funded, non-Federal governmental plan shall comply with section 164.504(f) of title 45, Code of Federal Regulations (or a successor regulation), and a plan sponsor shall act in accordance with the terms of the agreement described in such section.

(C) Rule of construction

Nothing in this section shall be construed to modify the requirements for the creation, receipt, maintenance, or transmission of protected health information under the HIPAA privacy regulations (45 C.F.R. parts 160 and 164, subparts A and E).

(3) Disclosure and redisclosure

(A) In general

A group health plan that is a self-funded, non-Federal governmental plan receiving information under paragraph (1) may disclose such information only—

(i)

to the entity from which the information was received or to that entity’s business associates as defined in section 160.103 of title 45, Code of Federal Regulations (or successor regulations); or

(ii)

as permitted by the HIPAA Privacy Rule (45 C.F.R. parts 160 and 164, subparts A and E).

(B) Rule of construction

Nothing in this section shall be construed to prevent a group health plan that is a self-funded, non-Federal governmental plan, or a health plan service provider providing services with respect to such a plan, from placing reasonable restrictions on the public disclosure of the information described in paragraph (1), except that such plan or entity may not restrict disclosure of such information to the Department of Health and Human Services, the Department of Labor, the Department of the Treasury, or the Comptroller General of the United States.

(C) Failure to provide

The obligation to provide information pursuant to this subsection shall exist notwithstanding the presence of any formal data-sharing agreement between the parties. Failure to provide the required information as specified shall constitute a violation of this Act and the Secretary shall initiate enforcement action under section 2723(b) (42 U.S.C. 300gg–22(b)) within 90 days of becoming aware of a violation of this section, except that nothing in this section shall be construed to limit the Secretary’s existing authority under this Act.

(4) Data format standards

All data and information provided pursuant to this subsection shall comply with the following standards:

(A)

All claims from a healthcare provider shall be made to the group health plan in accordance with standards adopted under HIPAA at section 162.1101 of title 45, Code of Federal Regulations, as follows:

(i)

Institutional, professional, and dental claims and adjustments to these claims shall be provided to the group health plan that is a self-funded, non-Federal governmental plan in the ASC X12N 837 format.

(ii)

Prescription drug claims shall be in the National Council for Prescription Drug Programs (NCPDP) format.

(iii)

The files shall be unmodified copies of the files sent from the provider. In the event that paper claims are sent by the provider, they shall be converted to the appropriate standard electronic format. Such data shall be provided at no cost to the group health plan.

(B)

All claim payment (or EFT, electronic funds transfer) and electronic remittance advice (ERA) information sent by a health plan service provider shall be provided to the group health plan or health insurance issuer in the ASC X12N 835 format, in accordance with standards adopted under HIPAA at section 162.1602 of title 45, Code of Federal Regulations, unmodified from the form in which it was transmitted to the healthcare provider. Such information shall be provided at no cost to the group health plan.

(C)

The Secretary may modify the standards set forth in this paragraph as necessary to align with any changes adopted by the Secretary pursuant to the authority provided under section 1173 of the Social Security Act (42 U.S.C. 1320d–2).

(c) Prohibited contractual provisions

Any provision in an agreement that unduly delays or limits a group health plan that is a self-funded, non-Federal governmental plan’s access to information described in this section or that restricts the format or timing of the provision of such information in a manner that is inconsistent with the requirements of this section shall be prohibited and, if a self-funded, non-Federal governmental plan enters into such agreement, shall be deemed void as against public policy.

(d) Regulations

The Secretary shall implement this section through notice and comment rulemaking in accordance with section 553 of title 5, United States Code.

(2) Penalty

Section 2723(b) of the Public Health Service Act (42 U.S.C. 300gg–22(b)) is amended by adding at the end the following:

(4) Enforcement authority relating to health plan service providers

Notwithstanding any provisions to the contrary, the Secretary may assess a penalty against a health plan service provider, as defined in section 2799A–12(a) (42 U.S.C. 300gg–121(a)), of $100,000 per day for each violation of such section, pursuant to substantially similar processes and procedures as those set forth in section 2723(b)(2)(D) through (G) (42 U.S.C. 300gg–121(b)(2)(D) through (G)).

(1) Emergency services

Section 2799A–1(f)(1)(C) of the Public Health Service Act (42 U.S.C. 300gg–111(f)(1)(C)) is amended to read as follows:

(C)

A good faith estimate of the amount the plan or coverage is responsible for paying for items and services included in the estimate described in subparagraph (B), including a plain language description of each item or service and all applicable billing codes for each item or service, including modifiers, using standard and commonly recognized billing code sets that are clearly identified.

(2) Explanation of benefits

Section 2799A–1 of the Public Health Service Act (42 U.S.C. 300gg–111) is amended by adding at the end the following:

(g) Explanation of benefits

(1) In general

For plan years beginning on or after January 1, 2027, each group health plan, or a health insurance issuer offering group or individual health insurance coverage shall, within 45 days of receiving any request for payment for an item or service under the plan, provide to the participant, beneficiary, or enrollee (through mail or electronic means, as requested by the participant, beneficiary, or enrollee) a notification (in clear and understandable language and utilizing substantially the same format as the advanced explanation of benefits required by subsection (f) to enable comparison) including the following:

(A)

Whether or not the provider or facility is a participating provider or a participating facility with respect to the plan or coverage with respect to the furnishing of such item or service.

(B)

An itemized explanation of benefits that includes the following:

(i)

A plain language description of each item or service.

(ii)

All applicable billing codes for each item or service, including modifiers, using standard and commonly recognized billing code sets that are clearly identified.

(iii)

The amount the plan or coverage is responsible for paying for each item or service.

(iv)

The amount of any cost-sharing for which the participant, beneficiary, or enrollee is responsible for each item or service (as of the date of such notification).

(v)

The amount that the participant, beneficiary, or enrollee has incurred toward meeting the limit of the financial responsibility (including with respect to deductibles and out-of-pocket maximums) under the plan or coverage (as of the date of such notification).

(vi)

The site of each item or service.

(2) Format

If applicable, the notification described in paragraph (1) may be provided in conjunction with, or as part of, a notice of a claim determination or other communication required by section 2719(a) (42 U.S.C. 300gg–19(a)), or regulations thereunder.

(h) Regulations

The Secretary shall implement this section through notice and comment rulemaking in accordance with section 553 of title 5, United States Code.

(1) Emergency services

Section 9816(f)(1)(C) of the Internal Revenue Code of 1986 is amended to read as follows:

(C)

A good faith estimate of the amount the plan is responsible for paying for items and services included in the estimate described in subparagraph (B), including a plain language description of each item or service and all applicable billing codes for each item or service, including modifiers, using standard and commonly recognized billing code sets that are clearly identified.

(2) Explanation of benefits

Section 9816 of the Internal Revenue Code of 1986 is amended by adding at the end the following:

(g) Explanation of benefits

(1) In general

For plan years beginning on or after January 1, 2027, each group health plan shall, within 45 days of receiving any request for payment for an item or service under the plan, provide to the participant or beneficiary (through mail or electronic means, as requested by the participant or beneficiary) a notification (in clear and understandable language and utilizing substantially the same format as the advanced explanation of benefits required by subsection (f) to enable comparison) including the following:

(A)

Whether or not the provider or facility is a participating provider or a participating facility with respect to the plan with respect to the furnishing of such item or service.

(B)

An itemized explanation of benefits that includes the following:

(i)

A plain language description of each item or service.

(ii)

All applicable billing codes for each item or service, including modifiers, using standard and commonly recognized billing code sets that are clearly identified.

(iii)

The amount the plan is responsible for paying for each item or service.

(iv)

The amount of any cost-sharing for which the participant or beneficiary is responsible for each item or service (as of the date of such notification).

(v)

The amount that the participant or beneficiary has incurred toward meeting the limit of the financial responsibility (including with respect to deductibles and out-of-pocket maximums) under the plan (as of the date of such notification).

(vi)

The site of each item or service.

(2) Format

If applicable, the notification described in paragraph (1) may be provided in conjunction with, or as part of, a notice of a claim determination or other communication required by section 503 of the Employee Retirement Income Security Act of 1974 or regulations thereunder.

(h) Regulations

The Secretary shall implement this section through notice and comment rulemaking in accordance with section 553 of title 5, United States Code.

(1) Emergency services

Section 716(f)(1)(C) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185e(f)(1)(C)) is amended to read as follows:

(C)

A good faith estimate of the amount the health plan is responsible for paying for items and services included in the estimate described in subparagraph (B), including a plain language description of each item or service and all applicable billing codes for each item or service, including modifiers, using standard and commonly recognized billing code sets that are clearly identified.

(2) Explanation of benefits

Section 716 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185e) is amended by adding at the end the following:

(g) Explanation of benefits

(1) In general

For plan years beginning on or after January 1, 2027, each group health plan or health insurance issuer offering group health insurance coverage shall, within 45 days of receiving any request for payment for an item or service under the plan, provide to the participant or beneficiary (through mail or electronic means, as requested by the participant or beneficiary) a notification (in clear and understandable language and utilizing substantially the same format as the advanced explanation of benefits required by subsection (f) to enable comparison) including the following:

(A)

Whether or not the provider or facility is a participating provider or a participating facility with respect to the plan or coverage with respect to the furnishing of such item or service.

(B)

An itemized explanation of benefits that includes the following:

(i)

A plain language description of each item or service.

(ii)

All applicable billing codes for each item or service, including modifiers, using standard and commonly recognized billing code sets that are clearly identified.

(iii)

The amount the plan or coverage is responsible for paying for each item or service.

(iv)

The amount of any cost-sharing for which the participant or beneficiary is responsible for each item or service (as of the date of such notification).

(v)

The amount that the participant or beneficiary has incurred toward meeting the limit of the financial responsibility (including with respect to deductibles and out-of-pocket maximums) under the plan or coverage (as of the date of such notification).

(vi)

The site of each item or service.

(2) Format

If applicable, the notification described in paragraph (1) may be provided in conjunction with, or as part of, a notice of a claim determination or other communication required by section 503 or regulations thereunder.

(h) Regulations

The Secretary shall implement this section through notice and comment rulemaking in accordance with section 553 of title 5, United States Code.

(1) In general

Section 1847A of the Social Security Act (42 U.S.C. 1395w–3a) is amended—

(2) Amounts payable; cost-sharing

Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended—

(3) ASC conforming amendments

Section 1833(i) of the Social Security Act (42 U.S.C. 1395l(i)) is amended by adding at the end the following new paragraph:

(11)

In the case of a selected drug (as defined in section 1192(c)), subject to a rebate under section 1847A(j) for which payment under this subsection is not packaged into a payment for a service furnished on or after the initial price applicability year for the selected drug under the revised payment system under this subsection, in lieu of calculation of coinsurance and the amount of payment otherwise applicable under this subsection, the provisions of section 1847(j)(2) and paragraph (1)(II) of subsection (a), shall, as determined appropriate by the Secretary, apply under this subsection in the same manner as such provisions of section 1847A(j)(2) and subsection (a) apply under such section and subsection.

(4) Opps conforming amendment

Section 1833(t)(8) of the Social Security Act (42 U.S.C. 1395l(t)(8)) is amended by adding at the end the following new subparagraph:

(G) Selected drugs subject to rebate

In the case of a selected drug (as defined in section 1192(c)), subject to a rebate under section 1847A(j) for which payment under this subsection is not packaged into a payment for a covered OPD service (or group of services) furnished on or after the initial price applicability year for the selected drug, and the payment for such drug is the same as the amount for a calendar quarter under section 1847A(b)(1)(B), under the system under this subsection, in lieu of the calculation of the copayment amount and the amount otherwise applicable under this subsection (other than the application of the limitation described in subparagraph (C)), the provisions of section 1847A(j)(2) and paragraph (1)(II) of subsection (a), shall, as determined by the Secretary apply under this section in the same manner as such provisions of section 1847A(j)(2) and subsection (a) apply under such section and subsection.

(5) Exclusion of selected drug mfp rebates from asp calculation

Section 1847A(c)(3) of the Social Security Act (42 U.S.C. 1395w–3a(c)(3)) is amended by striking subsection (i) and inserting subsection (i), subsection (j).

(6) Coordination with medicaid rebate information disclosures

Section 1927(b)(3)(D)(i) of the Social Security Act (42 U.S.C. 1396r–8(b)(3)(D)(i)) is amended by striking and the rebate and inserting and the rebates.

(7) Provision of rebates

Section 1193(a) of the Social Security Act (42 U.S.C. 1320f–2(a)) is amended—

(1)

Section 1847A(i)(5) of the Social Security Act (42 U.S.C. 1395w–3a(i)(5)) is amended, in the matter preceding subparagraph (A)—

(2)

Section 1833(a)(1)(EE) of the Social Security Act (42 U.S.C. 1395l(a)(1)(EE)) is amended—

(1)

The term covered individual has the meaning given that term in section 503(b)(6) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 353(b)(6)), as added by section 501 of this Act.

(2)

The term expanded-access prescription drugs means drugs covered under such section 503(b)(6).

(3)

The term Government sponsored program means any coverage described in section 5000A(f)(1)(A) of the Internal Revenue Code of 1986.

(1) Federal Reserve Act

Section 19 of the Federal Reserve Act (12 U.S.C. 461 et seq.) is amended—

(2) Financial Services Regulatory Relief Act of 2006

The Financial Services Regulatory Relief Act of 2006 is amended—