[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3282 Introduced in House (IH)]
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118th CONGRESS
1st Session
H. R. 3282
To amend title XVIII of the Social Security Act to promote transparency
of common ownership interests under parts C and D of the Medicare
program.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
May 15, 2023
Mrs. Harshbarger (for herself, Ms. Schrier, Mr. Bilirakis, and Ms.
Schakowsky) introduced the following bill; which was referred to the
Committee on Ways and Means, and in addition to the Committee on Energy
and Commerce, 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 XVIII of the Social Security Act to promote transparency
of common ownership interests under parts C and D of the Medicare
program.
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 ``Promoting Transparency and Healthy
Competition in Medicare Act''.
SEC. 2. PROMOTING TRANSPARENCY OF COMMON OWNERSHIP INTERESTS UNDER
PARTS C AND D OF THE MEDICARE PROGRAM.
(a) 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:
``(6) Required disclosure of certain information relating
to health care provider ownership.--
``(A) In general.--For plan years beginning on or
after January 1, 2025, a contract under this section
with an MA organization shall require the organization
to report to the Secretary, not later than 1 year after
the last day of such plan year, the information
described in subparagraph (B) with respect to such plan
year.
``(B) Information described.--For purposes of
subparagraph (A), the information described in this
subparagraph is, with respect to an MA organization and
a plan year, the following:
``(i) The number of items and services
furnished during such plan year by each
specified provider (as defined in subparagraph
(C)) for which payment was made by such
organization.
``(ii) The number of items and services
furnished during such plan year by providers of
services or suppliers not described in clause
(i) for which payment was made by such
organization.
``(iii) The average per-enrollee number of
qualifying diagnoses (as defined in
subparagraph (C)) made during such plan year by
specified providers (including through chart
reviews and health risk assessments) with
respect to individuals enrolled under an MA
plan offered by such organization, broken down
by site of service of such providers, as
specified by the Secretary.
``(iv) The average per-enrollee number of
qualifying diagnoses made during such plan year
by providers of services and suppliers not
described in clause (iii) (including through
such reviews and assessments) with respect to
such individuals, broken down by site of
service of such providers.
``(v) The average risk score (as calculated
under the methodology described in subparagraph
(C)(i)) for such an individual for such plan
year who received items and services from a
specified provider during such plan year.
``(vi) The average risk score for such an
individual for such plan year who did not
receive items and services from a specified
provider during such plan year.
``(vii) The average risk score for such an
individual for such plan year who received a
health risk assessment from an assessment
entity that was a specified assessment entity
during such plan year.
``(viii) The average risk score for such an
individual for such plan year who received a
health risk assessment from an assessment
entity that was not a specified assessment
entity during such plan year.
``(ix) The number of prior authorization
requests for an item or service submitted to
such organization during such plan year, the
number of such requests that were approved, the
number of such requests that were denied, and
the number of such denied requests that were
subsequently appealed and then approved, broken
down by whether the entity proposing to furnish
such item or service was a specified provider
or not a specified provider.
``(x) The total amount of incentive-based
payments made to, and the total amount of
shared losses recoupments collected from,
specified providers during such plan year.
``(xi) The total amount of incentive-based
payments made to, and the total amount of
shared losses recoupments collected from,
providers of services and suppliers not
described in clause (x) during such plan year.
``(xii) For each MA plan offered by such
organization during such plan year--
``(I) the total amount of payments
made under section 1853(a)(1) to such
organization for coverage of
individuals under such plan, and the
total amount of payments made by such
individuals to such organization for
coverage under such plan;
``(II) the total amount expended
under such plan as payment for items
and services furnished by each
specified provider during such year;
``(III) the total amount expended
under such plan as payment for items
and services furnished by providers of
services or suppliers not described in
subclause (II) during such year;
``(IV) the medical loss ratio under
such plan with respect to individuals
furnished an item or service from a
specified provider during such year;
and
``(V) the medical loss ratio under
such plan with respect to individuals
not described in subclause (IV).
``(C) Definitions.--In this paragraph:
``(i) Assessment entity.--The term
`assessment entity' means an entity with a
focus on furnishing in-home medical
assessments, as specified by the Secretary.
``(ii) Qualifying diagnosis.--The term
`qualifying diagnosis' means, with respect to
an individual, a diagnosis that is taken into
account in calculating a risk score for such
individual under the risk adjustment
methodology established by the Secretary
pursuant to section 1853(a)(3).
``(iii) Specified assessment entity.--The
term `specified assessment entity' means, with
respect to an MA organization and a plan year,
an assessment entity with respect to which such
organization (or any person with an ownership
or control interest (as defined in section
1124(a)(3)) in such organization) is a person
with an ownership or control interest (as so
defined).
``(iv) Specified provider.--The term
`specified provider' means, with respect to an
MA organization and a plan year, a provider of
services or supplier with respect to which such
organization (or any person with an ownership
or control interest (as defined in section
1124(a)(3)) in such organization) is a person
with an ownership or control interest (as so
defined).
``(D) Nonapplication of paperwork reduction act.--
Chapter 35 of title 44, United States Code, shall not
apply to information collected under this paragraph.''.
(b) Pharmacy Benefit Manager and Pharmacy Information.--Section
1860D-12(b) of the Social Security Act (42 U.S.C. 1395w-112(b)) is
amended by adding at the end the following new paragraphs:
``(9) Provision of information relating to pharmacy
ownership.--
``(A) In general.--For plan years beginning on or
after January 1, 2025, a contract entered into under
this part with a PDP sponsor shall require the sponsor
to report to the Secretary, not later than 1 year after
the last day of such plan year, the information
described in subparagraph (B) with respect to such plan
year.
``(B) Information described.--For purposes of
subparagraph (A), the information described in this
subparagraph is, for each prescription drug plan
offered by a PDP sponsor for a plan year, the
following:
``(i) The negotiated price for each covered
part D drug for which benefits are available
under such plan for each network pharmacy
(including an identification of whether each
such pharmacy is a specified pharmacy).
``(ii) The average per-drug amount of
direct and indirect remuneration paid by
specified pharmacies for such covered part D
drugs dispensed during such plan year under
such plan.
``(iii) The average per-drug amount of
direct and indirect remuneration paid by
pharmacies not described in clause (ii) for
such covered part D drugs dispensed during such
plan year under such plan.
``(C) Definitions.--In this paragraph:
``(i) Direct and indirect remuneration.--
The term `direct and indirect remuneration' has
the meaning given such term in section 423.308
of title 42, Code of Federal Regulations (or
any successor regulation).
``(ii) Network pharmacy.--The term `network
pharmacy' has the meaning given such term in
section 423.100 of title 42, Code of Federal
Regulations (or any successor regulation).
``(iii) Negotiated price.--The `negotiated
price' for a covered part D drug shall take
into account all negotiated price concessions,
such as discounts, direct or indirect
subsidies, rebates, and direct or indirect
remunerations, for such drug, and include any
dispensing fee for such drug.
``(iv) Specified pharmacy.--The term
`specified pharmacy' means, with respect to an
PDP sponsor and a plan year, a pharmacy with
respect to which such sponsor (or any person
with an ownership or control interest (as
defined in section 1124(a)(3)) in such sponsor)
is a person with an ownership or control
interest (as so defined).
``(D) Nonapplication of paperwork reduction act.--
Chapter 35 of title 44, United States Code, shall not
apply to information collected under this paragraph.
``(10) Provision of information by pharmacy benefit
managers.--
``(A) In general.--For plan years beginning on or
after January 1, 2025, a contract entered into under
this part with a PDP sponsor shall prohibit such
sponsor from entering into a contract with a specified
pharmacy benefit manager for purposes of performing any
service with respect to covered part D drugs dispensed
under any prescription drug plan offered by such
sponsor for such plan year unless such manager agrees
to report to the Secretary, not later than 1 year after
the last day of such plan year, the information
described in subparagraph (B) with respect to each
prescription drug plan for which such manager is
providing any such service during such plan year,
regardless of the sponsor of such plan.
``(B) Information described.--For purposes of
subparagraph (A), the information described in this
subparagraph is, with respect to a pharmacy benefit
manager performing services under a prescription drug
plan for a plan year, the following:
``(i) With respect to the total amount of
pharmacy and manufacturer rebates collected by
such manager (or collected on behalf of such
plan by any other entity with a contract in
effect with such manager for such collection)
for all covered part D drugs dispensed under
such plan during such plan year--
``(I) the total amount of such
rebates passed through to the PDP
sponsor of such plan; and
``(II) the total amount of such
rebates retained by such manager or
such other entities.
``(ii) The total amount paid by such
manager to pharmacies for drugs furnished under
such plan during such plan year.
``(iii) The total amount of payments made
by such sponsor to such manager as
reimbursement for such manager's payments
described in clause (ii).
``(iv) The total amount of payments made by
such sponsor to such manager as fees for
services furnished by such manager with respect
to such plan for such plan year (not including
payments described in clause (iii)).
``(v) The total amount of administrative
costs incurred by such manager for furnishing
such services under such plan for such plan
year.
``(vi) A specification as to whether such
manager is a specified pharmacy benefit manager
with respect to the PDP sponsor of such plan.
``(C) Definition.--In this paragraph, the term
`specified pharmacy benefit manager' means, with
respect to an PDP sponsor and a plan year, a pharmacy
benefit manager with respect to which such sponsor (or
any person with an ownership or control interest (as
defined in section 1124(a)(3)) in such sponsor) is a
person with an ownership or control interest (as so
defined).''.
(c) Publication.--Not later than January 1, 2027, the Secretary of
Health and Human Services shall establish a process under which
information submitted to the Secretary pursuant to the amendments made
by this section is publicly disclosed. Such process shall ensure that
any information so disclosed does not identify a specific drug
manufacturer, provider of services or supplier, pharmacy, pharmacy
benefit manager, or any price charged with respect to a particular
drug.
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