[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4883 Introduced in House (IH)]
<DOC>
118th CONGRESS
1st Session
H. R. 4883
To amend title XVIII of the Social Security Act to require the
disclosure of certain ownership information relating to health care
provider and pharmacy ownership, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 25, 2023
Mr. Murphy 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 require the
disclosure of certain ownership information relating to health care
provider and pharmacy ownership, and for other purposes.
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 ``Medicare Common Ownership
Transparency Act of 2023''.
SEC. 2. REPORT ON INTEGRATION IN MEDICARE.
(a) Required MA and PDP Reporting.--
(1) MA plans.--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 year 2025 and for every
third plan year thereafter, each MA organization
offering an MA plan under this part during such plan
year shall submit to the Secretary, at a time and in a
manner specified by the Secretary--
``(i) the taxpayer identification number
for each health care provider that was a
specified health care provider with respect to
such organization during such year;
``(ii) the total amount of incentive-based
payments made to, and the total amount of
shared losses recoupments collected from, such
specified health care providers during such
plan year; and
``(iii) 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 (ii) during such plan year.
``(B) Definition.--For purposes of this paragraph,
the term `specified health care 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).''.
(2) Prescription drug plans.--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 paragraph:
``(9) Provision of information relating to pharmacy
ownership.--
``(A) In general.--For plan year 2025 and for every
third plan year thereafter, each PDP sponsor offering a
prescription drug plan under this part during such plan
year shall submit to the Secretary, at a time and in a
manner specified by the Secretary, the taxpayer
identification number and National Provider Identifier
for each pharmacy that was a specified pharmacy with
respect to such sponsor during such year.
``(B) Definition.--For purposes of this paragraph,
the term `specified pharmacy' means, with respect to an
PDP sponsor offering a prescription drug plan and a
plan year, a pharmacy with respect to which--
``(i) 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); or
``(ii) a pharmacy benefit manager offering
services under such plan (or any person with an
ownership or control interest (as so defined)
in such sponsor) is a person with an ownership
or control interest (as so defined).''.
(b) MedPAC Reports.--Part E of title XVIII of the Social Security
Act (42 U.S.C. 1395x et seq.) is amended by adding at the end the
following new section:
``SEC. 1899C. REPORTS ON VERTICAL INTEGRATION UNDER MEDICARE.
``(a) In General.--Not later than June 15, 2029, and every 3 years
thereafter, the Medicare Payment Advisory Commission shall submit to
Congress a report on the state of vertical integration in the health
care sector during the applicable year with respect to entities
participating in the Medicare program, including health care providers,
pharmacies, prescription drug plan sponsors, Medicare Advantage
organizations, and pharmacy benefit managers. Such report shall
include--
``(1) with respect to Medicare Advantage organizations, the
evaluation described in subsection (b);
``(2) with respect to prescription drug plans, pharmacy
benefit managers, and pharmacies, the comparisons and
evaluations described in subsection (c);
``(3) with respect to Medicare Advantage plans under which
benefits are available for physician-administered drugs, the
information described in subsection (d); and
``(4) the identifications described in subsection (e); and
``(5) an analysis of the impact of such integration on
health care access, price, quality, and outcomes.
``(b) Medicare Advantage Organizations.--For purposes of subsection
(a)(1), the evaluation described in this subsection is, with respect to
Medicare Advantage organizations and an applicable year, an evaluation,
taking into account patient acuity and the types of areas serviced by
such organization, of--
``(1) the average number of qualifying diagnoses made
during such year with respect to enrollees of a Medicare
Advantage plan offered by such organization who, during such
year, received a health risk assessment from a specified health
care provider;
``(2) the average risk score for such enrollees who
received such an assessment during such year;
``(3) any relationship between such risk scores for such
enrollees receiving such an assessment from such a provider
during such year and incentive payments made to such providers;
``(4) the average risk score for enrollees of such plan who
received any item or service from a specified health care
provider during such year;
``(5) any relationship between the risk scores of enrollees
under such plan and whether the enrollees have received any
item or service from a specified provider; and
``(6) any relationship between the risk scores of enrollees
under such plan that have received any item or service from a
specified provider and incentive payments made under the plan
to specified providers.
``(c) Prescription Drug Plans.--For purposes of subsection (a)(2),
the comparisons and evaluations described in this subsection are, with
respect to prescription drug plans and an applicable year, the
following:
``(1) For each covered part D drug for which benefits are
available under such a plan, a comparison of the average
negotiated rate in effect with specified pharmacies with such
rates in effect for in-network pharmacies that are not
specified pharmacies.
``(2) Comparisons of the following:
``(A) The total amount paid by pharmacy benefit
managers to specified pharmacies for covered part D
drugs and the total amount so paid to pharmacies that
are not specified pharmacies for such drugs.
``(B) The total amount paid by such sponsors to
specified pharmacy benefit managers as reimbursement
for covered part D drugs and the total amount so paid
to pharmacy benefit managers that are not specified
pharmacy benefit managers as such reimbursement.
``(C) Fees paid under by plan to specified pharmacy
benefit managers compared to such fees paid to pharmacy
benefit managers that are not specified pharmacy
benefit managers.
``(3) An evaluation of the total amount of direct and
indirect remuneration for covered part D drugs passed through
to prescription drug plan sponsors and the total amount
retained by pharmacy benefit managers (including entities under
contract with such a manager).
``(4) To the extent that the available data permits, an
evaluation of fees charged by rebate aggregators that are
affiliated with plan sponsors.
``(d) Physician-Administered Drugs.--For purposes of subsection
(a)(3), the information described in this subsection is, with respect
to physician-administered drugs for which benefits are available under
a Medicare Advantage plan during an applicable year, the following:
``(1) With respect to each such plan, an identification of
each drug for which benefits were available under such plan
only when administered by a health care provider that acquired
such drug from an affiliated pharmacy.
``(2) An evaluation of the difference between the total
number of drugs administered by a health care provider that
were acquired from affiliated pharmacies compared to the number
of such drugs so administered that were acquired from
pharmacies other than affiliated pharmacies, and an evaluation
of the difference in payments for such drugs so administered
when acquired from a specified pharmacy and when acquired from
a pharmacy that is not a specified pharmacy.
``(3) An evaluation of the dollar value of all such drugs
that were not so administered because of a delay attributable
to an affiliated pharmacy compared to the dollar value of all
such drugs that were not so administered because of a delay
attributable to pharmacy that is not an affiliated pharmacy.
``(4) The number of enrollees administered such a drug that
was acquired from an affiliated pharmacy.
``(5) The number of enrollees furnished such a drug that
was acquired from a pharmacy that is not an affiliated
pharmacy.
``(e) Identifications.--For purposes of subsection (a)(4), the
identifications described in this subsection are, with respect to an
applicable year, identifications of each health care entity
participating under the Medicare program with respect to which another
health care entity so participating is a person with an ownership or
control interest (as defined in section 1124(a)(3) of the Social
Security Act (42 U.S.C. 1320a-3(a)(3))).
``(f) Definitions.--In this section:
``(1) Affiliated pharmacy.--The term `affiliated pharmacy'
means, with respect to a Medicare Advantage plan offered by a
Medicare Advantage organization, a pharmacy 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).
``(2) Applicable year.--The term `applicable year' means,
with respect to a report submitted under subsection (a), the
first calendar year beginning at least 4 years prior to the
date of the submission of such report.
``(3) Covered part d drug.--The term `covered part D drug'
has the meaning given such term in section 1860D-2(e).
``(4) 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).
``(5) Qualifying diagnosis.--The term `qualifying
diagnosis' means, with respect to an enrollee of a Medicare
Advantage plan, a diagnosis that is taken into account in
calculating a risk score for such enrollee under the risk
adjustment methodology established by the Secretary pursuant to
section 1853(a)(3).
``(6) Risk score.--The term `risk score' means, with
respect to an enrollee of a Medicare Advantage plan, the score
calculated for such individual using the methodology described
in paragraph (5).
``(7) Physician-administered drug.--The term `physician-
administered drug' means a drug furnished to an individual
that, had such individual been enrolled under part B and not
enrolled under part C, would have been payable under section
1842(o).
``(8) Specified health care provider.--The term `specified
health care provider' means, with respect to a Medicare
Advantage plan offered by a Medicare Advantage organization, a
health care provider 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).
``(9) Specified pharmacy.--The term `specified pharmacy'
means, with respect to a prescription drug plan offered by a
prescription drug plan sponsor, a pharmacy with respect to
which--
``(A) 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); or
``(B) a pharmacy benefit manager offering services
under such plan (or any person with an ownership or
control interest (as so defined) in such sponsor) is a
person with an ownership or control interest (as so
defined).
``(10) Specified pharmacy benefit manager.--The term
`specified pharmacy benefit manager' means, with respect to a
prescription drug plan offered by a prescription drug plan
sponsor, 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).''.
<all>