H.R. 9397

[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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