Premium Transparency Act

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 9397 Introduced in House (IH)]

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119th CONGRESS
  2d Session
                                H. R. 9397

 To amend title XXVII of the Public Health Service Act and title XVIII
  of the Social Security Act to ensure health insurer accountability
through publishing of overhead costs and claim payments, and to direct
  the Secretary of Health and Human Services to issue guidance on the
              provision of certain insurance information.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                             June 23, 2026

Mr. Pfluger (for himself and Mr. Moran) introduced the following bill;
  which was referred to the Committee on Energy and Commerce, and in
    addition to the Committee on Ways and Means, for a period to be
subsequently determined by the Speaker, in each case for consideration
  of such provisions as fall within the jurisdiction of the committee
                               concerned

_______________________________________________________________________

                                 A BILL

 To amend title XXVII of the Public Health Service Act and title XVIII
  of the Social Security Act to ensure health insurer accountability
through publishing of overhead costs and claim payments, and to direct
  the Secretary of Health and Human Services to issue guidance on the
              provision of certain insurance information.

    Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Premium Transparency Act''.

SEC. 2. ENSURING HEALTH INSURER ACCOUNTABILITY THROUGH PUBLISHING OF
              OVERHEAD COSTS AND CLAIM PAYMENTS.

    (a) In General.--Section 2718(a) of the Public Health Service Act
(42 U.S.C. 300gg-18(a)) is amended--
            (1) by redesignating paragraphs (1) through (3) as
        subparagraphs (A) through (C), and adjusting the margins
        accordingly;
            (2) by striking ``A health insurance issuer'' and inserting
        the following:
            ``(1) In general.--A health insurance issuer''; and
            (3) by adding at the end the following new paragraph:
            ``(2) Overhead costs and claim payment information.--
                    ``(A) In general.--A health insurance issuer
                offering group or individual health insurance coverage
                (including a grandfathered health plan) shall, with
                respect to each plan year beginning on or after January
                1, 2027, submit to the Secretary (and, in the case such
                coverage was offered through an Exchange established
                under subtitle D of title I of the Patient Protection
                and Affordable Care Act, to such Exchange) and publish
                on the public website of such issuer the following
                information in a consumer-friendly format specified by
                the Secretary:
                            ``(i) the percentage of total premium
                        revenue expended for each category described in
                        subparagraphs (A) through (C) of paragraph (1);
                            ``(ii) the explanation described in
                        paragraph (1)(C); and
                            ``(iii) the percentage of total premium
                        revenue not expended and retained by such
                        issuer.
                    ``(B) Manner of publication.--Information submitted
                and published by a health insurance issuer under
                subparagraph (A) shall be so submitted and published at
                the coverage level and shall in addition, if determined
                appropriate by the Secretary, be so submitted and
                published in the aggregate in such manner as specified
                by the Secretary (such as across all such coverage
                offered by such issuer that are offered within the same
                insurance market (as specified in subclause (I), (II),
                (III), or (IV) of section 2799A-1(a)(3)(E)(iv))).''.
    (b) Medicare Advantage.--Section 1857(e) of the Social Security Act
(42 U.S.C. 1395w-27(e)) is amended by adding at the end the following
new paragraph:
            ``(7) Overhead costs and claim payment information.--
                    ``(A) In general.--Beginning with plan years
                beginning on or after January 1, 2027, a contract under
                this section with an MA organization shall require the
                organization, with respect to each MA plan offered by
                such organization during such plan year, to submit to
                the Secretary and publish on the public website of such
                organization the following information in a consumer-
                friendly format specified by the Secretary:
                            ``(i) The amount of total revenue (as
                        determined under section 422.2420(c) of title
                        42, Code of Federal Regulations (or a successor
                        regulation)) collected under such plan.
                            ``(ii) The amount and percentage of such
                        revenue expended on incurred claims (as
                        determined in accordance with paragraphs (2)
                        through (4) of section 422.2420(b) of title 42,
                        Code of Federal Regulations (or a successor
                        regulation)).
                            ``(iii) The amount and percentage of such
                        revenue expended on non-claims costs (as
                        defined in section 422.2401 of title 42, Code
                        of Federal Regulations (or a successor
                        regulation)).
                            ``(iv) The amount of the difference between
                        the MLR numerator (as determined under
                        paragraph (b) of section 422.2420 of title 42,
                        Code of Federal Regulations (or a successor
                        regulation)) and the MLR denominator (as
                        determined under paragraph (c) of such section
                        (or a successor regulation)).
                            ``(v) The amount described in clause (iv),
                        expressed as a percentage of such revenue.
                    ``(B) Manner of publication.--Information submitted
                and published by an MA organization under subparagraph
                (A) shall be so submitted and published at the MA plan
                level and shall in addition, if determined appropriate
                by the Secretary, be so submitted and published in the
                aggregate in such manner as specified by the Secretary
                (such as across all MA plans offered by such
                organization).''.

SEC. 3. PROMOTING COMPARABILITY OF QUALIFIED HEALTH PLANS OFFERED
              THROUGH AN EXCHANGE.

    Section 1311(d)(4)(C) of the Patient Protection and Affordable Care
Act (42 U.S.C. 18031(d)(4)(C)) is amended--
            (1) by striking ``website through which'' and inserting the
        following: ``website--
                            ``(i) through which'';
            (2) in clause (i), as so inserted, by striking the
        semicolon and inserting ``; and''; and
            (3) by adding at the end the following new clause:
                            ``(ii) that includes, as part of such
                        comparative information for enrollments for
                        plan years beginning on or after January 1,
                        2029, in the case a qualified health plan
                        offered through such Exchange for such plan
                        year was offered through such Exchange for a
                        previous plan year, the most recent information
                        submitted to such Exchange with respect to such
                        plan by the health insurance issuer of such
                        plan under section 2718(a)(2) of the Public
                        Health Service Act;''.

SEC. 4. GUIDANCE ON PROVISION OF CERTAIN INSURANCE INFORMATION IN
              STANDARDIZED, PLAIN ENGLISH FORMAT.

    (a) In General.--Not later than January 1, 2028, the Secretary
shall issue guidance to group health plans, health insurance issuers
offering group or individual health insurance coverage, and Medicare
Advantage organizations offering an MA plan on providing information on
the benefits and coverage available under the applicable plan or
coverage, consistent with the relevant requirements under section 2715
of the Public Health Service Act (42 U.S.C. 300gg-15), section 1851(d)
of the Social Security Act (42 U.S.C. 1395w-21(d)), and section 1852(c)
of such Act (42 U.S.C. 1395w-22(c)). Such guidance shall include
standards for providing information in a standardized, plain English
format with respect to the following aspects of the plan or coverage
(to the extent applicable):
            (1) Any monthly premium.
            (2) Any annual deductible.
            (3) Any maximum limitations on out-of-pocket expenses.
            (4) The type of provider network used by the plan or
        coverage.
            (5) The plan or coverage share of the total allowed costs
        of benefits provided under the plan or coverage.
            (6) The standard cost-sharing amounts for in-network care,
        including for the following types of care:
                    (A) Primary care.
                    (B) Specialist care.
                    (C) Urgent care.
                    (D) Emergency department care.
                    (E) Imaging.
                    (F) Inpatient hospital care.
                    (G) Outpatient facility care.
                    (H) Laboratory services.
                    (I) Preferred brand name drugs.
                    (J) Generic drugs.
            (7) Additional features of the plan or coverage, including
        the following:
                    (A) Specialist referral policies.
                    (B) The availability of wellness programs.
                    (C) The availability of disease management
                programs.
                    (D) Whether an individual enrolled in such plan or
                coverage is an eligible individual for purposes of
                section 223 of the Internal Revenue Code of 1986
                (relating to health savings accounts).
                    (E) Coverage of preventive care services.
            (8) Such other aspects of the plan or coverage as the
        Secretary may specify.
    (b) Consultation.--In developing the guidance under subsection (a),
the Secretary shall consult with the Secretary of Labor and the
Secretary of the Treasury.
    (c) Rule of Construction.--Nothing in this section shall be
construed as requiring a group health plan, a health insurance issuer
offering group or individual health insurance coverage, or a Medicare
Advantage organization offering an MA plan to offer any of the plan
features described in subsection (a).
    (d) Definitions.--In this section:
            (1) Medicare advantage terms.--The terms ``Medicare
        Advantage organization'' and ``MA plan'' have the meanings
        given each such term for purposes of part C of title XVIII of
        the Social Security Act (42 U.S.C. 1395w-21 et seq.).
            (2) Private health insurance terms.--The terms ``group
        health plan'', ``health insurance coverage'', ``health
        insurance issuer'', ``group health insurance coverage'', and
        ``individual health insurance coverage'' have the meanings
        given each such term in section 2791 of the Public Health
        Service Act (42 U.S.C. 300gg-91).
            (3) Secretary.--The term ``Secretary'' means the Secretary
        of Health and Human Services.
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