[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4712 Introduced in House (IH)]
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118th CONGRESS
1st Session
H. R. 4712
To provide for increased oversight of entities that provide pharmacy
benefit management services on behalf of group health plans and health
insurance coverage.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 18, 2023
Mrs. Harshbarger (for herself and Ms. Manning) introduced the following
bill; which was referred to the Committee on Energy and Commerce, and
in addition to the Committees on Ways and Means, and Education and the
Workforce, 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 provide for increased oversight of entities that provide pharmacy
benefit management services on behalf of group health plans and health
insurance coverage.
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 ``Patient Right to Shop Act''.
SEC. 2. PROHIBITION ON BLOCKING CONSUMER DECISION-SUPPORT TOOLS.
(a) PHSA.--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:
``SEC. 2799A-11. PROHIBITION ON BLOCKING CONSUMER DECISION-SUPPORT
TOOLS.
``(a) In General.--A group health plan or a health insurance issuer
offering group or individual health insurance coverage shall not enter
into a contract with an entity that provides pharmacy benefit
management services with respect to such plan or coverage if such
contract includes any terms, conditions, or costs that would prevent or
restrict a covered third party from accessing or using information, for
purposes of the consumer decision-support tool, relevant to the
operability, implementation, and utilization of the consumer-decision
support tool regarding prescription drug benefits under the plan or
coverage that are administered by the entity providing pharmacy benefit
management services in contract with the plan or issuer.
``(b) Definitions.--In this section:
``(1) Consumer decision-support tool.--The term `consumer
decision-support tool' means a tool designed to inform
enrollees in a group health plan or health insurance coverage
about all costs to the enrollee for prescription drugs covered
by the plan or coverage, including out-of-pocket, copayment,
and coinsurance responsibility, as well as costs to the
enrollee, such as purchasing at the cash price or purchasing
through mail order pharmacy benefits.
``(2) Covered third party.--The term `covered third party'
means a third party that is in contract, as a business
associate (as defined in section 160.103 of title 45, Code of
Federal Regulations (or successor regulations)), with a group
health plan or a health insurance issuer offering group or
individual health insurance coverage to provide a consumer
decision-support tool.
``(c) Rules of Construction Regarding Privacy.--
``(1) Nothing in this section shall be construed to alter
existing obligations of a covered entity or business associate
under the privacy, security, and breach notification
regulations in parts 160 and 164 of title 45, Code of Federal
Regulations (or successor regulations).
``(2) Nothing in this section shall be construed to require
a group health plan, a health insurance issuer offering group
or individual health insurance coverage, or an entity providing
pharmacy benefit management services to share protected health
information, as defined in section 160.103 of title 45, Code of
Federal Regulations (or successor regulations), with a covered
third party.''.
(b) ERISA.--
(1) In general.--Subpart B of part 7 of subtitle B of title
I of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1185 et seq.) is amended by adding at the end the
following new section:
``SEC. 726. PROHIBITION ON BLOCKING CONSUMER DECISION-SUPPORT TOOLS.
``(a) In General.--A group health plan or a health insurance issuer
offering group health insurance coverage shall not enter into a
contract with an entity that provides pharmacy benefit management
services with respect to such plan or coverage if such contract
includes any terms, conditions, or costs that would prevent or restrict
a covered third party from accessing or using information, for purposes
of the consumer decision-support tool, relevant to the operability,
implementation, and utilization of the consumer-decision support tool
regarding prescription drug benefits under the plan or coverage that
are administered by the entity providing pharmacy benefit management
services in contract with the plan or issuer.
``(b) Definitions.--In this section:
``(1) Consumer decision-support tool.--The term `consumer
decision-support tool' means a tool designed to inform
participants and beneficiaries in a group health plan or health
insurance coverage about all costs to the participant or
beneficiary for prescription drugs covered by the plan or
coverage, including out-of-pocket, copayment, and coinsurance
responsibility, as well as costs to the participant or
beneficiary, such as purchasing at the cash price or purchasing
through mail order pharmacy benefits.
``(2) Covered third party.--The term `covered third party'
means a third party that is in contract, as a business
associate (as defined in section 160.103 of title 45, Code of
Federal Regulations (or successor regulations)), with a group
health plan or a health insurance issuer offering group health
insurance coverage to provide a consumer decision-support tool.
``(c) Rules of Construction.--
``(1) Nothing in this section shall be construed to alter
existing obligations of a covered entity or business associate
under the privacy, security, and breach notification
regulations in parts 160 and 164 of title 45, Code of Federal
Regulations (or successor regulations).
``(2) Nothing in this section shall be construed to require
a group health plan, a health insurance issuer offering group
health insurance coverage, or an entity providing pharmacy
benefit management services to share protected health
information, as defined in section 160.103 of title 45, Code of
Federal Regulations (or successor regulations), with a covered
third party.''.
(2) Clerical amendment.--The table of contents in section 1
of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1001 et seq.) is amended by inserting after the item
relating to section 725 the following:
``Sec. 726. Prohibition on blocking consumer decision-support tools.''.
(c) Internal Revenue Code.--
(1) In general.--Subchapter B of chapter 100 of the
Internal Revenue Code of 1986, as amended by section 2, is
further amended by adding at the end the following new section:
``SEC. 9826. PROHIBITION ON BLOCKING CONSUMER DECISION-SUPPORT TOOLS.
``(a) In General.--A group health plan offering group health
insurance coverage shall not enter into a contract with an entity that
provides pharmacy benefit management services with respect to such plan
if such contract includes any terms, conditions, or costs that would
prevent or restrict a covered third party from accessing or using
information, for purposes of the consumer decision-support tool,
relevant to the operability, implementation, and utilization of the
consumer-decision support tool regarding prescription drug benefits
under the plan that are administered by the entity providing pharmacy
benefit management services in contract with the plan.
``(b) Definitions.--In this section:
``(1) Consumer decision-support tool.--The term `consumer
decision-support tool' means a tool designed to inform
participants and beneficiaries in a group health plan about all
costs to the participant or beneficiary for prescription drugs
covered by the plan, including out-of-pocket, copayment, and
coinsurance responsibility, as well as costs to the participant
or beneficiary, such as purchasing at the cash price or
purchasing through mail order pharmacy benefits.
``(2) Covered third party.--The term `covered third party'
means a third party that is in contract, as a business
associate (as defined in section 160.103 of title 45, Code of
Federal Regulations (or successor regulations)), with a group
health plan or a health insurance issuer offering group health
insurance coverage to provide a consumer decision-support tool.
``(c) Rules of Construction.--
``(1) Nothing in this section shall be construed to alter
existing obligations of a covered entity or business associate
under the privacy, security, and breach notification
regulations in parts 160 and 164 of title 45, Code of Federal
Regulations (or successor regulations).
``(2) Nothing in this section shall be construed to require
a group health plan or an entity providing pharmacy benefit
management services to share protected health information, as
defined in section 160.103 of title 45, Code of Federal
Regulations (or successor regulations), with a covered third
party.''.
(2) Clerical amendment.--The table of sections for
subchapter B of chapter 100 of such Code is amended by adding
at the end the following new item:
``Sec. 9826. Prohibition on blocking consumer decision-support
tools.''.
(d) Application.--The amendments made by subsections (a), (b), and
(c) shall apply with respect to plan years beginning on or after the
date that is 2 years after the date of enactment of this Act.
(e) Regulations.--The Secretary of Health and Human Services, the
Secretary of Labor, and the Secretary of the Treasury shall jointly
promulgate regulations to carry out the amendments made by subsections
(a), (b), and (c), and shall issue draft regulations not later than 1
year after the date of enactment of this Act.
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