118 HR 4712 IH: Patient Right to Shop Act
U.S. House of Representatives
2023-07-18
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EN
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I
118th CONGRESS
1st Session
H. R. 4712
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.
1.

Short title
This Act may be cited as the “Patient Right to Shop Act”.
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:
“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:
“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:
“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.