I 

116TH CONGRESS 

2D SESSION H. R. 8098 

To address hospital consolidation and promote hospital price transparency, 

and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

AUGUST 25, 2020 

Mr. BANKS 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 the Judiciary, 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 address hospital consolidation and promote hospital price 

transparency, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Hospital Competition 

5 Act of 2020’’. 

6 SEC. 2. HOSPITAL CONSOLIDATION. 

7 (a) AUTHORIZATION OF APPROPRIATIONS.—There is 

8 authorized to be appropriated $160,000,000 to the Fed9 eral Trade Commission to hire staff to investigate, as conVerDate Sep 11 2014 00:30 Sep 06, 2020 Jkt 099200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H8098.IH H8098

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1 sistent with the Sherman Antitrust Act and other relevant 

2 Federal laws, anti-competitive mergers and practices 

3 under such laws to the extent such mergers and practices 

4 relate to providers of inpatient and outpatient health care 

5 services, as defined by the Secretary of Health and 

6 Human Services. 

7 (b) MEDICARE ADVANTAGE RATES APPLIED TO CER8 TAIN HHI HOSPITALS.— 

9 (1) IN GENERAL.—Section 1866(a) of the So10 cial Security Act (42 U.S.C. 1395cc(a)) is amend11 ed— 

12 (A) in paragraph (1)— 

13 (i) in subparagraph (X), by striking 

14 ‘‘and’’ at the end; 

15 (ii) in subparagraph (Y), by striking 

16 the period at the end and inserting ‘‘; 

17 and’’; and 

18 (iii) by inserting after subparagraph 

19 (Y) the following new subparagraph: 

20 ‘‘(Z) subject to paragraph (4), in the case 

21 of a hospital located in a county whose popu22 lation density is above the median population 

23 density for all counties in the United States 

24 with respect to which there is a Herfindahl25 Hirschman Index (HHI) of greater than 4,000, 


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1 to apply the average reimbursement rate with 

2 respect to individuals (regardless of whether 

3 such an individual is entitled to or eligible for 

4 benefits under this title, but excluding individ5 uals eligible for medical assistance under a 

6 State plan under title XIX) furnished items and 

7 services at such hospital that would be billable 

8 under this title for such items and services if 

9 furnished by such hospital to an individual en10 rolled under part C.’’; and 

11 (B) by adding at the end the following new 

12 paragraph: 

13 ‘‘(4)(A) The requirement under paragraph 

14 (1)(Z) shall not apply in the case of a hospital in a 

15 hospital referral region if— 

16 ‘‘(i) the HRR market share of such hos17 pital (as determined under subparagraph (B)) 

18 is less than 0.15; or 

19 ‘‘(ii) the hospital is located in a rural area 

20 (as defined in section 1886(d)(2)(D)); 

21 ‘‘(B) For purposes of subparagraph (A), the 

22 HRR market share of a hospital in a hospital refer23 ral region is equal to— 

24 ‘‘(i) the total revenue of the hospital, di25 vided by 


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1 ‘‘(ii) the total revenue of all hospital in the 

2 hospital referral region.’’. 

3 (2) EFFECTIVE DATE.—The amendments made 

4 by this subsection shall apply with respect to items 

5 and services furnished on or after January 1, 2021. 

6 (c) GRANTS FOR HOSPITAL INFRASTRUCTURE IM7 PROVEMENT.— 

8 (1) IN GENERAL.—The Secretary of Health and 

9 Human Services shall carry out a grant program 

10 under which the Secretary shall provide grants to el11 igible States, in accordance with this subsection. 

12 (2) USES.—An eligible State receiving a grant 

13 under this subsection may use such grant to improve 

14 the State hospital infrastructure and to supplement 

15 any other funds provided for a purpose authorized 

16 under a State or local hospital grant programs 

17 under State law. 

18 (3) ELIGIBILITY.— 

19 (A) IN GENERAL.—An eligible State may 

20 receive not more than one grant under this sub21 section with respect to each qualifying criterion 

22 described in subparagraph (B) that is met by 

23 the State. 

24 (B) ELIGIBLE STATE.—For purposes of 

25 this subsection, the term ‘‘eligible State’’ means 


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1 a State that meets any one or more of the fol2 lowing qualifying criteria: 

3 (i) The State does not have in effect 

4 any State certificate of need law that re5 quires a health care provider to provide to 

6 a regulatory body a certification that the 

7 community needs the services provided by 

8 the health care provider. 

9 (ii) The State has in effect State 

10 scope of practice laws that— 

11 (I) allow advanced practice pro12 viders (such as nurse practitioners, 

13 advanced practice registered nurses, 

14 clinical nurse specialists, and physi15 cian assistants) to evaluate patients; 

16 diagnose, order, and interpret diag17 nostic tests; and initiate and manage 

18 treatments; or 

19 (II) provide that the only jus20 tification for limiting the scope of 

21 practice of a health care provider is 

22 safety to the public. 

23 (iii) The State does not have in effect 

24 any State laws that require managed care 

25 plans to accept into the network of such 


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1 plan any qualified provider who is willing 

2 to accept the terms and conditions of the 

3 managed care plan. 

4 (iv) The State does not have in effect 

5 any Certificate of Public Advantage laws 

6 that clearly articulate the State’s intent to 

7 displace competition in favor of regulation 

8 or that violate State or Federal antitrust 

9 laws. 

10 (v) The State does not have in effect 

11 any network adequacy laws regulating a 

12 health plan’s ability to deliver benefits by 

13 providing reasonable access to a sufficient 

14 number of in-network primary care and 

15 specialty physicians, as well as all health 

16 care services included under the terms of 

17 an insuree’s contract with a health insurer. 

18 (4) FUNDING.—There is authorized to be ap19 propriated to carry out this subsection 

20 $1,000,000,000 for each of the fiscal years 2021 

21 through 2030. Funds appropriated under this para22 graph shall remain available until expended. 

23 (d) CRITICAL ACCESS HOSPITAL REIMBURSEMENT

24 RATES.— 


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1 (1) PART A.—Section 1814(l)(1) of the Social 

2 Security Act (42 U.S.C. 1395f(l)(1)) is amended by 

3 inserting ‘‘(or, for 2021, 102, plus 1 percentage 

4 point for each subsequent year through 2029, and 

5 110 for each subsequent year thereafter)’’ after 

6 ‘‘101’’. 

7 (2) PART B.—Section 1834(g)(1) of such Act 

8 (42 U.S.C. 1395m(g)(1)) is amended by inserting 

9 ‘‘(or, for 2021, 102, plus 1 percentage point for each 

10 subsequent year through 2029, and 110 for each 

11 subsequent year thereafter)’’ after ‘‘101’’. 

12 SEC. 3. PRICE TRANSPARENCY. 

13 Section 1866 of the Social Security Act (42 U.S.C. 

14 1395cc), as amended by section 401, is further amended— 

15 (1) in subsection (a)(1)— 

16 (A) in subparagraph (Y), by striking 

17 ‘‘and’’ at the end; 

18 (B) in subparagraph (Z), by striking the 

19 period at the end and inserting ‘‘; and’’; and 

20 (C) by inserting after subparagraph (Z) 

21 the following new subparagraph: 

22 ‘‘(AA) in the case of a hospital, to comply with 

23 the requirement under subsection (l).’’; and 

24 (2) by adding at the end the following new sub25 section: 


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1 ‘‘(l) REQUIREMENT RELATING TO PUBLISHING CER2 TAIN HOSPITAL PRICES.— 

3 ‘‘(1) IN GENERAL.—For purposes of subsection 

4 (a)(1)(AA), the requirement described in this sub5 section is, with respect to a hospital and year (begin6 ning with 2021), for the hospital to publicly post, 

7 through the system established under paragraph (3), 

8 for each commonly shoppable service included in the 

9 list published under paragraph (2) for such year, the 

10 volume-weighted average price charged by the hos11 pital to— 

12 ‘‘(A) individuals enrolled during such year 

13 in group health plans or health insurance cov14 erage offered in the individual or group market 

15 (as such terms are defined in section 2791 of 

16 the Public Health Service Act); and 

17 ‘‘(B) individuals who are not enrolled in 

18 any health insurance coverage or health benefits 

19 plan and individuals who are enrolled in such 

20 coverage or plan but such coverage or plan does 

21 not provide benefits for the service. 

22 ‘‘(2) COMMONLY SHOPPABLE SERVICES.—For 

23 purposes of subsection (a)(1)(AA) and this sub24 section, the Secretary shall, for 2021 and each sub25 sequent year, publish a list of the 100 commonly 


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1 shoppable services that are the most highly utilized 

2 in a hospital-based setting. 

3 ‘‘(3) STANDARDIZED DIGITAL REPORTING SYS4 TEM.—Not later than January 1, 2021, the Sec5 retary shall establish a standardized digital system 

6 for purposes of paragraph (1).’’. 

7 SEC. 4. REPEALING ELIGIBILITY OF CERTAIN ACOS. 

8 (a) IN GENERAL.—Section 1899(b)(1) of the Social 

9 Security Act (42 U.S.C. 1395jjj(b)(1)) is amended by 

10 striking subparagraphs (C) through (E). 

11 (b) EFFECTIVE DATE.—The amendment made by 

12 subsection (a) shall take effect on January 1, 2021. 

13 SEC. 5. OFF-CAMPUS PROVIDER-BASED DEPARTMENT 

14 MEDICARE SITE NEUTRAL PAYMENT. 

15 (a) IN GENERAL.—Section 1834 of the Social Secu16 rity Act (42 U.S.C. 1395m) is amended by adding at the 

17 end the following new subsection: 

18 ‘‘(x) OFF-CAMPUS PROVIDER-BASED DEPARTMENT

19 SITE NEUTRAL PAYMENT.— 

20 ‘‘(1) IN GENERAL.—With respect to items and 

21 services furnished in an off-campus provider-based 

22 department, payment under this section for such 

23 items and services shall be the amount determined 

24 under the fee schedule under section 1848 for such 


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1 items and services furnished if furnished in a physi2 cian office setting. 

3 ‘‘(2) OFF-CAMPUS PROVIDER-BASED DEPART4 MENT.—For purposes of this subsection, the term 

5 ‘off-campus provider-based department’ has such 

6 meaning as specified by the Secretary.’’. 

7 (b) EFFECTIVE DATE.—The amendment made by 

8 subsection (a) shall apply with respect to items and serv9 ices furnished on or after January 1, 2021. 

10 SEC. 6. REPEAL OF HEALTH CARE REFORM PROVISIONS 

11 LIMITING MEDICARE EXCEPTION TO THE 

12 PROHIBITION ON CERTAIN PHYSICIAN RE13 FERRALS FOR HOSPITALS. 

14 Sections 6001 and 10601 of the Patient Protection 

15 and Affordable Care Act (Public Law 111–148; 124 Stat. 

16 684, 1005) and section 1106 of the Health Care and Edu17 cation Reconciliation Act of 2010 (Public Law 111–152; 

18 124 Stat. 1049) are repealed and the provisions of law 

19 amended by such sections are restored as if such sections 

20 had never been enacted. 

21 SEC. 7. ADVISORY GROUP ON REDUCING BURDEN OF HOS22 PITAL ADMINISTRATIVE REQUIREMENTS. 

23 (a) IN GENERAL.—Not later than January 1, 2021, 

24 the Secretary of Health and Human Services shall convene 

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1 tion, recommendations on ways the Federal Government 

2 could reduce the burden of administrative requirements on 

3 hospitals. 

4 (b) RECOMMENDATIONS.—Not later than January 1, 

5 2022, the advisory board convened under this section 

6 shall— 

7 (1) submit to the Secretary of Health and 

8 Human Services recommendations described under 

9 subsection (a) for executive action and any rec10 ommendations for State actions for potential consid11 eration in making grants under section 2(c) to 

12 States; and 

13 (2) submit to Congress recommendations de14 scribed under subsection (a) for legislative proposals. 

15 (c) MEMBERSHIP.—The advisory board under this 

16 section shall consist of the following members: 

17 (1) Three representatives of companies that 

18 have— 

19 (A) geographically distributed workforces; 

20 (B) at least 10,000 employees; and 

21 (C) no more than 10 percent of such em22 ployees in any single State. 

23 (2) Three representatives of health insurance 

24 issuers and health plans, consisting of— 


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1 (A) one representative of for-profit health 

2 insurance issuers and health plans with at least 

3 20,000,000 enrollees in the employer-sponsored 

4 market; 

5 (B) one representative of non-profit health 

6 insurance issuers and health plans operating in 

7 at least 5 States; and 

8 (C) one representative of non-profit health 

9 insurance issuers and health plans operating in 

10 a rural State (as defined by the Census Bu11 reau). 

12 (3) Seven public policy experts in the field of 

13 hospital consolidation. 

14 SEC. 8. AUTHORITY OF FEDERAL TRADE COMMISSION 

15 OVER CERTAIN TAX-EXEMPT ORGANIZA16 TIONS. 

17 Section 4 of the Federal Trade Commission Act (15 

18 U.S.C. 44) is amended, in the undesignated paragraph re19 lating to the definition of the term ‘‘Corporation’’— 

20 (1) by striking ‘‘, and any’’ and inserting ‘‘, 

21 any’’; and 

22 (2) by inserting before the period at the end the 

23 following: ‘‘, and any organization described in sec24 tion 501(c)(3) of the Internal Revenue Code of 1986 


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1 that is exempt from taxation under section 501(a) of 

2 such Code’’. 

3 SEC. 9. LEVELING THE PLAYING FIELD BETWEEN PRO4 VIDERS AND PAYERS. 

5 (a) EXEMPTION.—It shall not be a violation of the 

6 antitrust laws for one or more private health insurer 

7 issuers or their designated agents to jointly negotiate 

8 prices of particular hospital services with a hospital pro9 vider with regards to the reimbursement policies of the 

10 insurers for those services. 

11 (b) DEFINITIONS.—For purposes of this section: 

12 (1) ANTITRUST LAWS.—The term ‘‘antitrust 

13 laws’’ has the meaning given it in subsection (a) of 

14 the 1st section of the Clayton Act (15 U.S.C. 12(a)), 

15 except that such term includes section 5 of the Fed16 eral Trade Commission Act (15 U.S.C. 45) to the 

17 extent such section 5 applies to unfair methods of 

18 competition. 

19 (2) HEALTH INSURANCE ISSUER.—The term 

20 ‘‘health insurance issuer’’ means an insurance com21 pany, insurance service, or insurance organization 

22 (including a health maintenance organization, as de23 fined in subparagraph (C)) which is licensed to en24 gage in the business of insurance in a State and 

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1 ance (within the meaning of section 514(b)(2) of the 

2 Employee Retirement Income Security Act of 1974 

3 (29 U.S.C. 1144(b)(2)). Such term does not include 

4 a group health plan. 

5 (3) HEALTH MAINTENANCE ORGANIZATION.— 

6 The term ‘‘health maintenance organization’’ 

7 means— 

8 (A) a federally qualified health mainte9 nance organization (as defined in section 

10 300e(a) of title 42 of the Code of Federal Reg11 ulations), 

12 (B) an organization recognized under State 

13 law as a health maintenance organization, or 

14 (C) a similar organization regulated under 

15 State law for solvency in the same manner and 

16 to the same extent as such a health mainte17 nance organization. 

18 (c) EFFECTIVE DATE.—This section shall take effect 

19 on the date of the enactment of this Act but shall not 

20 apply with respect to conduct that occurs before such date. 

21 SEC. 10. INCREASING TRANSPARENCY BY REMOVING GAG 

22 CLAUSES ON PRICE AND QUALITY INFORMA23 TION. 

24 Subpart II of part A of title XXVII of the Public 

25 Health Service Act (42 U.S.C. 300gg–11 et seq.), as 


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1 amended by section 103, is amended by adding at the end 

2 the following: 

3 ‘‘SEC. 2729B. INCREASING TRANSPARENCY BY REMOVING 

4 GAG CLAUSES ON PRICE AND QUALITY IN5 FORMATION. 

6 ‘‘(a) INCREASING PRICE AND QUALITY TRANS7 PARENCY FOR PLAN SPONSORS AND GROUP AND INDI8 VIDUAL MARKET AND CONSUMERS.— 

9 ‘‘(1) GROUP HEALTH PLANS.—A group health 

10 plan or health insurance issuer offering group health 

11 insurance coverage may not enter into an agreement 

12 with a health care provider, network or association 

13 of providers, third-party administrator, or other 

14 service provider offering access to a network of pro15 viders that would directly or indirectly restrict a 

16 group health plan or health insurance issuer from— 

17 ‘‘(A) providing provider-specific cost or 

18 quality of care information, through a consumer 

19 engagement tool or any other means, to refer20 ring providers, the plan sponsor, enrollees, or 

21 eligible enrollees of the plan or coverage; 

22 ‘‘(B) electronically accessing de-identified 

23 claims and encounter data for each enrollee in 

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1 gated pursuant to section 264(c) of the Health 

2 Insurance Portability and Accountability Act, 

3 the amendments to this Act made by the Ge4 netic Information Nondiscrimination Act of 

5 2008, and the Americans with Disabilities Act 

6 of 1990, with respect to the applicable health 

7 plan or health insurance coverage, including, on 

8 a per claim basis— 

9 ‘‘(i) financial information, such as the 

10 allowed amount, or any other claim-related 

11 financial obligations included in the pro12 vider contract; 

13 ‘‘(ii) provider information, including 

14 name and clinical designation; 

15 ‘‘(iii) service codes; or 

16 ‘‘(iv) any other data element normally 

17 included in claim or encounter transactions 

18 when received by a plan or issuer; or 

19 ‘‘(C) sharing data described in subpara20 graph (A) or (B) with a business associate as 

21 defined in section 160.103 of title 45, Code of 

22 Federal Regulations (or successor regulations), 

23 consistent with the privacy regulations promul24 gated pursuant to section 264(c) of the Health 

25 Insurance Portability and Accountability Act, 


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1 the amendments to this Act made by the Ge2 netic Information Nondiscrimination Act of 

3 2008, and the Americans with Disabilities Act 

4 of 1990. 

5 ‘‘(2) INDIVIDUAL HEALTH INSURANCE COV6 ERAGE.—A health insurance issuer offering indi7 vidual health insurance coverage may not enter into 

8 an agreement with a health care provider, network 

9 or association of providers, or other service provider 

10 offering access to a network of providers that would 

11 directly or indirectly restrict the health insurance 

12 issuer from— 

13 ‘‘(A) providing provider-specific price or 

14 quality of care information, through a consumer 

15 engagement tool or any other means, to refer16 ring providers, enrollees, or eligible enrollees of 

17 the plan or coverage; or 

18 ‘‘(B) sharing, for plan design, plan admin19 istration, and plan, financial, legal, and quality 

20 improvement activities, data described in sub21 paragraph (A) with a business associate as de22 fined in section 160.103 of title 45, Code of 

23 Federal Regulations (or successor regulations), 

24 consistent with the privacy regulations promul25 gated pursuant to section 264(c) of the Health 


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1 Insurance Portability and Accountability Act, 

2 the amendments to this Act made by the Ge3 netic Information Nondiscrimination Act of 

4 2008, and the Americans with Disabilities Act 

5 of 1990. 

6 ‘‘(3) CLARIFICATION REGARDING PUBLIC DIS7 CLOSURE OF INFORMATION.—Nothing in paragraph 

8 (1)(A) or (2)(A) prevents a health care provider, 

9 network or association of providers, or other service 

10 provider from placing reasonable restrictions on the 

11 public disclosure of the information described in 

12 such paragraphs (1) and (2). 

13 ‘‘(4) ATTESTATION.—A group health plan or a 

14 health insurance issuer offering group or individual 

15 health insurance coverage shall annually submit to, 

16 as applicable, the applicable authority described in 

17 section 2723 or the Secretary of Labor, an attesta18 tion that such plan or issuer is in compliance with 

19 the requirements of this subsection. 

20 ‘‘(5) RULE OF CONSTRUCTION.—Nothing in 

21 this section shall be construed to otherwise limit 

22 group health plan, plan sponsor, or health insurance 

23 issuer access to data currently permitted under the 

24 privacy regulations promulgated pursuant to section 

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1 countability Act, the amendments to this Act made 

2 by the Genetic Information Nondiscrimination Act of 

3 2008, and the Americans with Disabilities Act of 

4 1990.’’. 

5 SEC. 11. BANNING ANTICOMPETITIVE TERMS IN FACILITY 

6 AND INSURANCE CONTRACTS THAT LIMIT AC7 CESS TO HIGHER QUALITY, LOWER COST 

8 CARE. 

9 (a) IN GENERAL.—Section 2729B of the Public 

10 Health Service Act, as added by section 301, is amended 

11 by adding at the end the following: 

12 ‘‘(b) PROTECTING HEALTH PLANS NETWORK DE13 SIGN FLEXIBILITY.— 

14 ‘‘(1) IN GENERAL.—A group health plan or a 

15 health insurance issuer offering group or individual 

16 health insurance coverage shall not enter into an 

17 agreement with a provider, network or association of 

18 providers, or other service provider offering access to 

19 a network of service providers if such agreement, di20 rectly or indirectly— 

21 ‘‘(A) restricts the group health plan or 

22 health insurance issuer from— 

23 ‘‘(i) directing or steering enrollees to 

24 other health care providers; or 


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1 ‘‘(ii) offering incentives to encourage 

2 enrollees to utilize specific health care pro3 viders; or 

4 ‘‘(B) requires the group health plan or 

5 health insurance issuer to enter into any addi6 tional contract with an affiliate of the provider, 

7 such as an affiliate of the provider, as a condi8 tion of entering into a contract with such pro9 vider; 

10 ‘‘(C) requires the group health plan or 

11 health insurance issuer to agree to payment 

12 rates or other terms for any affiliate not party 

13 to the contract of the provider involved; or 

14 ‘‘(D) restricts other group health plans or 

15 health insurance issuers not party to the con16 tract from paying a lower rate for items or 

17 services than the contracting plan or issuer 

18 pays for such items or services. 

19 ‘‘(2) ADDITIONAL REQUIREMENT FOR SELF-IN20 SURED PLANS.—A self-insured group health plan 

21 shall not enter into an agreement with a provider, 

22 network or association of providers, third-party ad23 ministrator, or other service provider offering access 

24 to a network of providers if such agreement directly 

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1 tify, attest, or otherwise confirm in writing that the 

2 group health plan is bound by restrictive contracting 

3 terms between the service provider and a third-party 

4 administrator that the group health plan is not 

5 party to, without a disclosure that such terms exist. 

6 ‘‘(3) EXCEPTION FOR CERTAIN GROUP MODEL

7 ISSUERS.—Paragraph (1)(A) shall not apply to a 

8 group health plan or health insurance issuer offering 

9 group or individual health insurance coverage with 

10 respect to— 

11 ‘‘(A) a health maintenance organization 

12 (as defined in section 2791(b)(3)), if such 

13 health maintenance organization operates pri14 marily through exclusive contracts with multi15 specialty physician groups, nor to any arrange16 ment between such a health maintenance orga17 nization and its affiliates; or 

18 ‘‘(B) a value-based network arrangement, 

19 such as an exclusive provider network, account20 able care organization, center of excellence, a 

21 provider sponsored health insurance issuer that 

22 operates primarily through aligned multi-spe23 cialty physician group practices or integrated 

24 health systems, or such other similar network 


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1 arrangements as determined by the Secretary 

2 through rulemaking. 

3 ‘‘(4) ATTESTATION.—A group health plan or 

4 health insurance issuer offering group or individual 

5 health insurance coverage shall annually submit to, 

6 as applicable, the applicable authority described in 

7 section 2723 or the Secretary of Labor, an attesta8 tion that such plan or issuer is in compliance with 

9 the requirements of this subsection. 

10 ‘‘(c) MAINTENANCE OF EXISTING HIPAA, GINA, 

11 AND ADA PROTECTIONS.—Nothing in this section shall 

12 modify, reduce, or eliminate the existing privacy protec13 tions and standards provided by reason of State and Fed14 eral law, including the requirements of parts 160 and 164 

15 of title 45, Code of Federal Regulations (or any successor 

16 regulations). 

17 ‘‘(d) REGULATIONS.—The Secretary, not later than 

18 1 year after the date of enactment of the Hospital Com19 petition Act of 2020, shall promulgate regulations to carry 

20 out this section. 

21 ‘‘(e) RULE OF CONSTRUCTION.—Nothing in this sec22 tion shall be construed to limit network design or cost or 

23 quality initiatives by a group health plan or health insur24 ance issuer, including accountable care organizations, ex25 clusive provider organizations, networks that tier providers 


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1 by cost or quality or steer enrollees to centers of excel2 lence, or other pay-for-performance programs. 

3 ‘‘(f) CLARIFICATION WITH RESPECT TO ANTITRUST

4 LAWS.—Compliance with this section does not constitute 

5 compliance with the antitrust laws, as defined in sub6 section (a) of the first section of the Clayton Act (15 

7 U.S.C. 12(a)).’’. 

8 (b) EFFECTIVE DATE.—Section 2729B of the Public 

9 Health Service Act (as added by section 301 and amended 

10 by subsection (a)) shall apply with respect to any contract 

11 entered into on or after the date that is 18 months after 

12 the date of enactment of this Act. With respect to an ap13 plicable contract that is in effect on the date of enactment 

14 of this Act, such section 2729B shall apply on the earlier 

15 of the date of renewal of such contract or 3 years after 

16 such date of enactment. 

17 SEC. 12. DESIGNATION OF A NONGOVERNMENTAL, NON18 PROFIT TRANSPARENCY ORGANIZATION TO 

19 LOWER AMERICANS’ HEALTH CARE COSTS. 

20 (a) IN GENERAL.—Subpart C of title XXVII of the 

21 Public Health Service Act (42 U.S.C. 300gg–91 et seq.), 

22 as amended by section 102, is further amended by adding 

23 at the end the following: 


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1 ‘‘SEC. 2796. DESIGNATION OF A NONGOVERNMENTAL, NON2 PROFIT TRANSPARENCY ORGANIZATION TO 

3 LOWER AMERICANS’ HEALTH CARE COSTS. 

4 ‘‘(a) IN GENERAL.—The Secretary, in consultation 

5 with the Secretary of Labor, not later than 1 year after 

6 the date of enactment of the Hospital Competition Act of 

7 2020, shall enter into contracts with at least 2 nonprofit 

8 entities to support the establishment and maintenance of 

9 a database that receives and utilizes health care claims 

10 information and related information and issues reports 

11 that are available to the public and authorized users, and 

12 are submitted to the Department of Health and Human 

13 Services. 

14 ‘‘(b) REQUIREMENTS.— 

15 ‘‘(1) IN GENERAL.—The database established 

16 under subsection (a) shall— 

17 ‘‘(A) improve transparency by using de18 identified health care data to— 

19 ‘‘(i) inform patients about the cost, 

20 quality, and value of their care; 

21 ‘‘(ii) assist providers and hospitals, as 

22 they work with patients, to make informed 

23 choices about care; 

24 ‘‘(iii) enable providers, hospitals, and 

25 communities to improve services and out26 comes for patients by benchmarking their 


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1 performance against that of other pro2 viders, hospitals, and communities; 

3 ‘‘(iv) enable purchasers, including em4 ployers, employee organizations, and health 

5 plans, to develop value-based purchasing 

6 models, improve quality, and reduce the 

7 cost of health care and insurance coverage 

8 for enrollees; 

9 ‘‘(v) enable employers and employee 

10 organizations to evaluate network design 

11 and construction, and the cost of care for 

12 enrollees; 

13 ‘‘(vi) facilitate State-led initiatives to 

14 lower health care costs and improve qual15 ity; and 

16 ‘‘(vii) promote competition based on 

17 quality and cost; 

18 ‘‘(B) collect medical claims, prescription 

19 drug claims, and remittance data consistent 

20 with the protections and requirements of sub21 section (d); 

22 ‘‘(C) be established in such a manner that 

23 allows the data collected pursuant to subpara24 graph (B) to be shared with any State all-payer 

25 claims database or regional database operated 


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1 with authorization from States, at cost, using a 

2 standardized format, if such State or regional 

3 database also submits claims data to the data4 base established under this section; and 

5 ‘‘(D) be available to— 

6 ‘‘(i) the Director of the Congressional 

7 Budget Office, the Comptroller General of 

8 the United States, the Executive Director 

9 of the Medicare Payment Advisory Com10 mission, and the Executive Director of the 

11 Medicaid and CHIP Payment Advisory 

12 Commission, upon request, subject to the 

13 privacy and security requirements of au14 thorized users under subsection (e)(2); and 

15 ‘‘(ii) authorized users, including em16 ployers, employee organizations, providers, 

17 group health plans, health insurance 

18 issuers, researchers, and policymakers, 

19 subject to subsection (e). 

20 ‘‘(2) PRIVACY AND SECURITY; BREACH NOTIFI21 CATIONS.— 

22 ‘‘(A) REGULATIONS.— 

23 ‘‘(i) IN GENERAL.—The Secretary 

24 shall issue regulations prescribing the ex25 tent to which, and the manner in which, 


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1 the following rules (and any successors of 

2 such rules) shall apply to the activities 

3 under this section of an entity receiving a 

4 contract under subsection (a): 

5 ‘‘(I) The Privacy Rule under part 

6 160 and subparts A and E of part 

7 164 of title 45, Code of Federal Regu8 lations (or any successor regulations). 

9 ‘‘(II) The Security Rule under 

10 part 160 and subparts A and C of 

11 part 164 of such title 45 (or any suc12 cessor regulations). 

13 ‘‘(III) The Breach Notification 

14 Rule under part 160 and subparts A 

15 and D of part 164 of such title 45 (or 

16 any successor regulations). 

17 ‘‘(ii) SUPPLEMENTAL REGULA18 TIONS.—In order to ensure data privacy 

19 and security and the notification of 

20 breaches, the Secretary may issue such 

21 supplemental regulations on the subjects of 

22 the rules listed under clause (i) as the Sec23 retary determines appropriate to address 

24 differences between the activities described 


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1 by this section and the activities covered by 

2 such rules. 

3 ‘‘(B) ENFORCEMENT.—Section 1176 of 

4 Social Security Act shall apply with respect to 

5 a violation of this paragraph in the same man6 ner such section 1176 applies to a violation of 

7 part C of title XI of the Social Security Act, 

8 and the Secretary may include in the regula9 tions promulgated under this section provisions 

10 to apply such section to this paragraph. 

11 ‘‘(C) PROCEDURE.— 

12 ‘‘(i) TIMING.—The Secretary shall 

13 issue the initial set of regulations under 

14 this paragraph not later than 1 year after 

15 the date of enactment of the Hospital 

16 Competition Act of 2020. 

17 ‘‘(ii) AUTHORITY TO USE INTERIM

18 FINAL PROCEDURES.—The Secretary may 

19 make such initial set of regulations effec20 tive and final immediately upon issuance, 

21 on an interim basis, and provide for a pe22 riod of public comment on such initial set 

23 of regulations after the date of publication. 


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1 ‘‘(D) REQUIREMENTS OF ENTITY.—An en2 tity receiving the contract under this section 

3 shall— 

4 ‘‘(i) not disclose to the public any in5 dividually identifiable health information; 

6 ‘‘(ii) strictly limit staff access to the 

7 data to staff with appropriate training, 

8 clearance, and background checks and re9 quire regular privacy and security training; 

10 ‘‘(iii) maintain effective security 

11 standards for transferring data or making 

12 data available to authorized users; 

13 ‘‘(iv) develop a process for providing 

14 access to data to authorized users, in a se15 cure manner that maintains privacy and 

16 confidentiality of data; and 

17 ‘‘(v) adhere to current best security 

18 practices with respect to the management 

19 and use of such data for health services re20 search, in accordance with applicable Fed21 eral privacy law. 

22 ‘‘(3) CONSULTATION.— 

23 ‘‘(A) ADVISORY COMMITTEE.—Not later 

24 than 180 days after the date of enactment of 

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1 retary shall convene an Advisory Committee 

2 (referred to in this section as the ‘Committee’), 

3 consisting of 13 members, to advise the Sec4 retary, a contracting entity, and Congress on 

5 the establishment, operations, and use of the 

6 database established under this section. 

7 ‘‘(B) MEMBERSHIP.— 

8 ‘‘(i) APPOINTMENT.—In accordance 

9 with clause (ii), the Secretary, in consulta10 tion with the Secretary of Labor and the 

11 Comptroller General of the United States 

12 shall, not later than 180 days after the 

13 date of enactment of the Hospital Com14 petition Act of 2020, appoint members to 

15 the Committee who have distinguished 

16 themselves in the fields of health services 

17 research, health economics, health 

18 informatics, or the governance of State all19 payer claims databases, or who represent 

20 organizations likely to submit data to or 

21 use the database, including patients, em22 ployers, or employee organizations that 

23 sponsor group health plans, health care 

24 providers, health insurance issuers, or 

25 third-party administrators of group health 


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1 plans. Such members shall serve 3-year 

2 terms on a staggered basis. Vacancies on 

3 the Committee shall be filled by appoint4 ment consistent with this subsection not 

5 later than 3 months after the vacancy 

6 arises. 

7 ‘‘(ii) COMPOSITION.—In accordance 

8 with clause (i)— 

9 ‘‘(I) the Secretary, in consulta10 tion with the Secretary of Labor, shall 

11 appoint to the Committee— 

12 ‘‘(aa) 1 member selected by 

13 the Secretary, in coordination 

14 with the Secretary of Labor, to 

15 serve as the chair of the Com16 mittee; 

17 ‘‘(bb) the Assistant Sec18 retary for Planning and Evalua19 tion of the Department of Health 

20 and Human Services, or a des21 ignee of such Assistant Sec22 retary; 

23 ‘‘(cc) 1 representative of the 

24 Centers for Medicare & Medicaid 

25 Services; 


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1 ‘‘(dd) 1 representative of the 

2 Agency for Health Research and 

3 Quality; 

4 ‘‘(ee) 1 representative of the 

5 Office for Civil Rights of the De6 partment of Health and Human 

7 Services with expertise in data 

8 privacy and security; 

9 ‘‘(ff) 1 representative of the 

10 National Center for Health Sta11 tistics; and 

12 ‘‘(gg) 1 representative of the 

13 Employee Benefits and Security 

14 Administration of the Depart15 ment of Labor; and 

16 ‘‘(II) the Comptroller General of 

17 the United States shall appoint to the 

18 Committee— 

19 ‘‘(aa) 1 representative of an 

20 employer that sponsors a group 

21 health plan; 

22 ‘‘(bb) 1 representative of an 

23 employee organization that spon24 sors a group health plan; 


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1 ‘‘(cc) 1 academic researcher 

2 with expertise in health econom3 ics or health services research; 

4 ‘‘(dd) 1 consumer advocate; 

5 and 

6 ‘‘(ee) 2 additional members. 

7 ‘‘(C) DUTIES.—The Committee shall— 

8 ‘‘(i) advise the Secretary on the man9 agement of the contract under subsection 

10 (a); 

11 ‘‘(ii) assist and advise the entities re12 ceiving the contract under subsection (a) in 

13 establishing— 

14 ‘‘(I) the scope and format of the 

15 data to be submitted under subsection 

16 (d); 

17 ‘‘(II) best practices with respect 

18 to de-identification of data, as appro19 priate; 

20 ‘‘(III) the appropriate uses of 

21 data by authorized users, including 

22 developing standards for the approval 

23 of requests by organizations to access 

24 and use the data; and 


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1 ‘‘(IV) the appropriate formats 

2 and methods for making reports and 

3 analyses based on the database to the 

4 public; 

5 ‘‘(iii) conduct an annual review of 

6 whether data was used according to the 

7 appropriate uses as described in clause 

8 (ii)(II), and advise the designated entities 

9 on using the data for authorized purposes; 

10 ‘‘(iv) report, as appropriate, to the 

11 Secretary and Congress on the operation of 

12 the database and opportunities to better 

13 achieve the objectives of this section; 

14 ‘‘(v) establish additional restrictions 

15 on researchers who receive compensation 

16 from entities described in subsection 

17 (e)(2)(B)(ii), in order to protect individ18 ually identifiable health information; and 

19 ‘‘(vi) establish objectives for research 

20 and public reporting. 

21 ‘‘(4) STATE REQUIREMENTS.—A State may re22 quire health insurance issuers and other payers to 

23 submit claims data to the database established 

24 under this section, provided that such data is sub25 mitted to the entities awarded contracts under this 


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1 section in a form and manner established by the 

2 Secretary, and pursuant to subsection (d)(4)(B). 

3 ‘‘(5) SANCTIONS.—The Secretary shall take ap4 propriate action to sanction users who attempt to re5 identify data accessed pursuant to paragraph 

6 (1)(D). 

7 ‘‘(c) CONTRACT REQUIREMENTS.— 

8 ‘‘(1) COMPETITIVE PROCEDURES.—The Sec9 retary shall enter into the contract under subsection 

10 (a) using full and open competition procedures pur11 suant to chapter 33 of title 41, United States Code. 

12 ‘‘(2) ELIGIBLE ENTITIES.—To be eligible to 

13 enter into a contract described in subsection (a), an 

14 entity shall— 

15 ‘‘(A) be a private nonprofit entity governed 

16 by a board that includes representatives of the 

17 academic research community and individuals 

18 with expertise in employer-sponsored insurance, 

19 research using health care claims data and ac20 tuarial analysis; 

21 ‘‘(B) conduct its business in an open and 

22 transparent manner that provides the oppor23 tunity for public comment on its activities; and 


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1 ‘‘(C) agree to comply with any require2 ments imposed under the rulemaking described 

3 in subsection (d)(4)(A). 

4 ‘‘(3) CONSIDERATIONS.—In awarding a con5 tract under subsection (a), the Secretary shall con6 sider an entity’s experience in— 

7 ‘‘(A) health care claims data collection, ag8 gregation, quality assurance, analysis, and secu9 rity; 

10 ‘‘(B) supporting academic research on 

11 health costs, spending, and utilization for and 

12 by privately insured patients; 

13 ‘‘(C) working with large health insurance 

14 issuers and third-party administrators to as15 semble a national claims database; 

16 ‘‘(D) effectively collaborating with and en17 gaging stakeholders to develop reports; 

18 ‘‘(E) meeting budgets and timelines, in19 cluding in connection with report generation; 

20 and 

21 ‘‘(F) facilitating the creation of, or sup22 porting, State all-payer claims databases. 

23 ‘‘(4) CONTRACT TERM.—A contract awarded 

24 under this section shall be for a period of 5 years, 


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1 and may be renewed after a subsequent competitive 

2 bidding process under this section. 

3 ‘‘(5) TRANSITION OF CONTRACT.—If the Sec4 retary, following a competitive process at the end of 

5 the contract period, selects a new entity to maintain 

6 the database, all data shall be transferred to the new 

7 entity according to a schedule and process to be de8 termined by the Secretary. Upon termination of a 

9 contract, no entity may keep data held by the data10 base or disclose such data to any entity other than 

11 the entity so designated by the Secretary. The Sec12 retary shall include enforcement terms in any con13 tract with an organization chosen under this section, 

14 to ensure the timely transfer of all data, and any as15 sociated code or algorithms, to a new entity in the 

16 event of contract termination. 

17 ‘‘(d) RECEIVING HEALTH INFORMATION.— 

18 ‘‘(1) REQUIREMENTS.— 

19 ‘‘(A) IN GENERAL.—The Secretary of 

20 Labor shall ensure that the applicable self-in21 sured group health plan, through its third-party 

22 administrator, pharmacy benefit manager, or 

23 other entity designated by the group health 

24 plan, as applicable, electronically submits all 


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1 claims data with respect to the plan, pursuant 

2 to subparagraph (B). 

3 ‘‘(B) SCOPE OF INFORMATION AND FOR4 MAT OF SUBMISSION.—An entity awarded the 

5 contract under subsection (a), in consultation 

6 with the Committee described in subsection 

7 (b)(3), and pursuant to the privacy and security 

8 requirements of subsection (b)(2), shall— 

9 ‘‘(i) specify the data elements required 

10 to be submitted under subparagraph (A), 

11 which shall include all data related to 

12 transactions described in subparagraphs 

13 (A) and (E) of section 1173(a)(2) of the 

14 Social Security Act, including all data ele15 ments normally present in such trans16 actions when adjudicated, and enrollment 

17 information; 

18 ‘‘(ii) specify the form and manner for 

19 such submissions, and the historical period 

20 to be included in the initial submission; 

21 and 

22 ‘‘(iii) offer an automated submission 

23 option to minimize administrative burdens 

24 for entities required to submit data. 


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1 ‘‘(C) DE-IDENTIFICATION OF DATA.—An 

2 entity awarded the contract under subsection 

3 (a) shall— 

4 ‘‘(i) establish a process under which 

5 data is de-identified consistent with the de6 identification requirements under section 

7 164.514 of title 45, Code of Federal Regu8 lations (or any successor regulations), 

9 while retaining the ability to link data lon10 gitudinally for the purposes of research on 

11 cost and quality, and the ability to com12 plete risk adjustment and geographic anal13 ysis; 

14 ‘‘(ii) ensure that any third-party sub15 contractors who perform the de-identifica16 tion process described in clause (i) retain 

17 only the minimum necessary information 

18 to perform such a process, and adhere to 

19 effective security and encryption practices 

20 in data storage and transmission; 

21 ‘‘(iii) store claims and other data col22 lected under this subsection only in de23 identified form, in accordance with section 

24 164.514 of title 45, Code of Federal Regu25 lations (or any successor regulations); and 


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1 ‘‘(iv) ensure that individually identifi2 able data is encrypted, in accordance with 

3 guidance issued by the Secretary under 

4 section 13402(h)(2) of the HITECH Act. 

5 ‘‘(2) APPLICABLE SELF-INSURED GROUP

6 HEALTH PLAN.—For purposes of paragraph (1), a 

7 self-insured group health plan is an applicable self8 insured group health plan if such plan is self-admin9 istered, or is administered by a third-party plan ad10 ministrator that meets 1 or both of the following cri11 teria: 

12 ‘‘(A) Administers health, medical, or phar13 macy benefits for more than 50,000 enrollees. 

14 ‘‘(B) Is one of the 5 largest administrators 

15 or issuers of self-insured group health plans in 

16 a State in which such administrator operates, 

17 as measured by the aggregate number of enroll18 ees in plans administered by such administrator 

19 in such State, as determined by the Secretary. 

20 ‘‘(3) THIRD-PARTY ADMINISTRATORS.—In the 

21 case of a third-party administrator that is required 

22 under this subsection to submit claims data with re23 spect to an applicable self-insured group health plan, 

24 such administrator shall submit claims data with re25 spect to all self-insured group health plans that the 


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1 administrator administers, including such plans that 

2 are not applicable self-insured group health plans, as 

3 described in paragraph (2). 

4 ‘‘(4) RECEIVING OTHER INFORMATION.— 

5 ‘‘(A) MEDICARE DATA.—The Secretary, 

6 through rulemaking, shall ensure that the data 

7 made available to such entity is available to 

8 qualified entities under section 1874(e) of the 

9 Social Security Act is made available to each 

10 entity awarded a contract under subsection (a). 

11 ‘‘(B) STATE DATA.—An entity awarded a 

12 contract under subsection (a) shall collect data 

13 from State all payer claims databases that seek 

14 access to the database established under this 

15 section. 

16 ‘‘(5) AVAILABILITY OF DATA.—An entity re17 quired to submit data under this subsection may not 

18 place any restrictions on the use of such data by au19 thorized users. 

20 ‘‘(e) USES OF INFORMATION.— 

21 ‘‘(1) IN GENERAL.—An entity awarded a con22 tract under subsection (a) shall make the database 

23 available to users who are authorized under this sub24 section, without charge, and reports and analyses 


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1 based on the data available to the public with no 

2 charge. 

3 ‘‘(2) AUTHORIZATION OF USERS.— 

4 ‘‘(A) IN GENERAL.—An entity may request 

5 authorization by an entity awarded a contract 

6 under subsection (a) for access to the database 

7 in accordance with this paragraph. 

8 ‘‘(B) APPLICATION.—An entity desiring 

9 authorization under this paragraph shall submit 

10 to an entity awarded a contract an application 

11 for such access, which shall include— 

12 ‘‘(i) in the case of an entity requesting 

13 access for research purposes— 

14 ‘‘(I) a description of the uses and 

15 methodologies for evaluating health 

16 system performance using such data; 

17 and 

18 ‘‘(II) documentation of approval 

19 of the research by an institutional re20 view board, if applicable for a par21 ticular plan of research; or 

22 ‘‘(ii) in the case of an entity such as 

23 an employer, health insurance issuer, 

24 third-party administrator, or health care 

25 provider, requesting access for the purpose 


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1 of quality improvement or cost-contain2 ment, a description of the intended uses 

3 for such data. 

4 ‘‘(C) REQUIREMENTS.— 

5 ‘‘(i) RESEARCH.—Upon approval of 

6 an application for research purposes under 

7 subparagraph (B)(i), the authorized user 

8 shall enter into a data use and confiden9 tiality agreement with an entity awarded a 

10 contract under subsection (a), which shall 

11 include a prohibition on attempts to re12 identify and disclose individually identifi13 able health information. 

14 ‘‘(ii) QUALITY IMPROVEMENT AND

15 COST-CONTAINMENT.—In consultation with 

16 the Committee described in subsection 

17 (b)(3), the Secretary shall, through rule18 making, establish the form and manner in 

19 which authorized users described in sub20 paragraph (B)(ii) may access data. Data 

21 provided to such authorized users shall be 

22 provided in a form and manner such that 

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1 thorized user shall enter into a data use 

2 and confidentiality agreement with the en3 tity. 

4 ‘‘(iii) CUSTOMIZED REPORTS.—Em5 ployers and employer organizations may 

6 request customized reports from an entity 

7 awarded a contract under subsection (a), 

8 at cost, subject to the requirements of this 

9 section with respect to privacy and secu10 rity. 

11 ‘‘(iv) NON-CUSTOMIZED REPORTS.— 

12 An entity awarded a contract under sub13 section (a), in consultation with the Com14 mittee, shall make available to all author15 ized users aggregate data sets, free of 

16 charge. 

17 ‘‘(f) FUNDING.— 

18 ‘‘(1) INITIAL FUNDING.—There are authorized 

19 to be appropriated, and there are appropriated, out 

20 of monies in the Treasury not otherwise appro21 priated, $20,000,000 for fiscal year 2020, for the 

22 implementation of the initial contract and establish23 ment of the database under this section. 

24 ‘‘(2) ONGOING FUNDING.—There are author25 ized to be appropriated $15,000,000 for each of fisVerDate Sep 11 2014 00:30 Sep 06, 2020 Jkt 099200 PO 00000 Frm 00044 Fmt 6652 Sfmt 6201 E:\BILLS\H8098.IH H8098

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1 cal years 2021 through 2025, for purposes of car2 rying out this section (other than the grant program 

3 under subsection (h)). 

4 ‘‘(g) ANNUAL REPORT.— 

5 ‘‘(1) SUBMISSION.—On each of the dates de6 scribed in paragraph (2), an entity receiving a con7 tract under subsection (a) shall submit to Congress, 

8 the Secretary of Health and Human Services, and 

9 the Secretary of Labor and publish online for access 

10 by the general public, a report containing a descrip11 tion of— 

12 ‘‘(A) trends in the price, utilization, and 

13 total spending on health care services, including 

14 a geographic analysis of differences in such 

15 trends; 

16 ‘‘(B) limitations in the data set; 

17 ‘‘(C) progress towards the objectives of 

18 this section; and 

19 ‘‘(D) the performance by the entity of the 

20 duties required under such contract. 

21 ‘‘(2) DATES DESCRIBED.—The reports de22 scribed in paragraph (1) shall be submitted— 

23 ‘‘(A) not later than 3 years after the date 

24 of enactment of the Hospital Competition Act 

25 of 2020; 


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1 ‘‘(B) the later of 1 year after the date that 

2 is 3 years after such date of enactment or 

3 March 1 of the year after the date that is 3 

4 years after such date of enactment; and 

5 ‘‘(C) March 1 of each year thereafter. 

6 ‘‘(3) PUBLIC REPORTS AND RESEARCH.—An 

7 entity receiving a contract under subsection (a) 

8 shall, in coordination with authorized users, make 

9 analyses and research available to the public on an 

10 ongoing basis to promote the objectives of this sec11 tion. 

12 ‘‘(h) GRANTS TO STATES.— 

13 ‘‘(1) IN GENERAL.—The Secretary, in consulta14 tion with the Secretary of Labor, may award grants 

15 to States for the purpose of establishing and main16 taining State all-payer claims databases that im17 prove transparency of data in order to meet the 

18 goals of subsection (a)(1). 

19 ‘‘(2) REQUIREMENT.—To be eligible to receive 

20 the funding under paragraph (1), a State shall sub21 mit data to the database as described in subsection 

22 (b)(1)(C), using the format described in subsection 

23 (d)(1). 

24 ‘‘(3) FUNDING.—There is authorized to be ap25 propriated $100,000,000 for the period of fiscal 


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1 years 2020 through 2029 for the purpose of award2 ing grants to States under this subsection. 

3 ‘‘(i) EXEMPTION FROM PUBLIC DISCLOSURE.— 

4 ‘‘(1) IN GENERAL.—Claims data provided to 

5 the database, and the database itself shall not be 

6 considered public records and shall be exempt from 

7 public disclosure requirements. 

8 ‘‘(2) RESTRICTIONS ON USES FOR CERTAIN

9 PROCEEDINGS.—Data disclosed to authorized users 

10 shall not be subject to discovery or admission as 

11 public information, or evidence in judicial or admin12 istrative proceedings without consent of the affected 

13 parties. 

14 ‘‘(j) INDIVIDUALLY IDENTIFIABLE HEALTH INFOR15 MATION DEFINED.—The term ‘individually identifiable 

16 health information’ has the meaning given such term in 

17 section 1171(6) of the Social Security Act. 

18 ‘‘(k) RULE OF CONSTRUCTION.—Nothing in this sec19 tion shall be construed to affect or modify enforcement 

20 of the privacy, security, or breach notification rules pro21 mulgated under section 264(c) of the Health Insurance 

22 Portability and Accountability Act of 1996 (or successor 

23 regulations).’’. 

24 (b) GAO REPORT.— 


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1 (1) IN GENERAL.—The Comptroller General of 

2 the United States shall conduct a study on— 

3 (A) the performance of the entity awarded 

4 a contract under section 2795(a) of the Public 

5 Health Service Act, as added by subsection (a), 

6 under such contract; 

7 (B) the privacy and security of the infor8 mation reported to the entity; and 

9 (C) the costs incurred by such entity in 

10 performing such duties. 

11 (2) REPORTS.—Not later than 2 years after the 

12 effective date of the first contract entered into under 

13 section 2795(a) of the Public Health Service Act, as 

14 added by subsection (a), and again not later than 4 

15 years after such effective date, the Comptroller Gen16 eral of the United States shall submit to Congress 

17 a report containing the results of the study con18 ducted under paragraph (1), together with rec19 ommendations for such legislation and administra20 tive action as the Comptroller General determines 

21 appropriate. 


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1 SEC. 13. PROTECTING PATIENTS AND IMPROVING THE AC2 CURACY OF PROVIDER DIRECTORY INFOR3 MATION. 

4 (a) IN GENERAL.—Subpart II of part A of title 

5 XXVII of the Public Health Service Act (42 U.S.C. 

6 300gg–11 et seq.), as amended by sections 301 and 302, 

7 is further amended by adding at the end the following: 

8 ‘‘SEC. 2729C. PROTECTING PATIENTS AND IMPROVING THE 

9 ACCURACY OF PROVIDER DIRECTORY INFOR10 MATION. 

11 ‘‘(a) NETWORK STATUS OF PROVIDERS.— 

12 ‘‘(1) IN GENERAL.—Beginning on the date that 

13 is one year after the date of enactment of this sec14 tion, a group health plan or a health insurance 

15 issuer offering group or individual health insurance 

16 coverage shall— 

17 ‘‘(A) establish business processes to ensure 

18 that all enrollees in such plan or coverage re19 ceive proof of a health care provider’s network 

20 status, based on what a plan or issuer knows or 

21 could reasonably know— 

22 ‘‘(i) through a written electronic com23 munication from the plan or issuer to the 

24 enrollee, as soon as practicable and not 

25 later than 1 business day after a telephone 


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1 inquiry is made by such enrollee for such 

2 information; 

3 ‘‘(ii) through an oral confirmation, 

4 documented by such issuer or coverage, 

5 and kept in the enrollee’s file for a min6 imum of 2 years; and 

7 ‘‘(iii) in real-time through an online 

8 health care provider directory search tool 

9 maintained by the plan or issuer; and 

10 ‘‘(B) include in any print directory a dis11 closure that the information included in the di12 rectory is accurate as of the date of the last 

13 data update and that enrollees or prospective 

14 enrollees should consult the group health plan 

15 or issuer’s electronic provider directory on its 

16 website or call a specified customer service tele17 phone number to obtain the most current pro18 vider directory information. 

19 ‘‘(2) GROUP HEALTH PLAN AND HEALTH IN20 SURANCE ISSUER BUSINESS PROCESSES.—Beginning 

21 on the date that is one year after the date of enact22 ment of the Hospital Competition Act of 2020, a 

23 group health plan or a health insurance issuer offer24 ing group or individual health insurance coverage 

25 shall establish business processes to— 


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1 ‘‘(A) verify and update, at least once every 

2 90 days, the provider directory information for 

3 all providers included in the online health care 

4 provider directory search tool described in para5 graph (1)(A)(iii); and 

6 ‘‘(B) remove any provider from such online 

7 directory search tool if such provider has not 

8 verified the directory information within the 

9 previous 6 months or the plan or issuer has 

10 been unable to verify the provider’s network 

11 participation. 

12 ‘‘(b) COST-SHARING LIMITATIONS.— 

13 ‘‘(1) IN GENERAL.—A group health plan or a 

14 health insurance issuer offering group or individual 

15 health insurance coverage shall not apply, and shall 

16 ensure that no provider applies cost-sharing to an 

17 enrollee for treatment or services provided by a 

18 health care provider in excess of the normal cost19 sharing applied for in-network care (including any 

20 balance bill issued by the health care provider in21 volved), if such enrollee, or health care provider re22 ferring such enrollee, demonstrates (based on the 

23 electronic, written information described in sub24 section (a)(1)(A)(i), the oral confirmation described 

25 in subsection (a)(1)(A)(ii), or a copy of the online 


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1 provider directory described in subsection 

2 (a)(1)(A)(iii) on the date the enrollee attempted to 

3 obtain the provider’s network status) that the en4 rollee relied on the information described in sub5 section (a)(1), if the provider’s network status or di6 rectory information on such directory was incorrect 

7 at the time the treatment or services involved was 

8 provided. 

9 ‘‘(2) REFUNDS TO ENROLLEES.—If a health 

10 care provider submits a bill to an enrollee in viola11 tion of paragraph (1), and the enrollee pays such 

12 bill, the provider shall reimburse the enrollee for the 

13 full amount paid by the enrollee in excess of the in14 network cost-sharing amount for the treatment or 

15 services involved, plus interest, at an interest rate 

16 determined by the Secretary. 

17 ‘‘(c) PROVIDER BUSINESS PROCESSES.—A health 

18 care provider shall have in place business processes to en19 sure the timely provision of provider directory information 

20 to a group health plan or a health insurance issuer offer21 ing group or individual health insurance coverage to sup22 port compliance by such plans or issuers with subsection 

23 (a)(1). Such providers shall submit provider directory in24 formation to a plan or issuers, at a minimum— 


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1 ‘‘(1) when the provider begins a network agree2 ment with a plan or with an issuer with respect to 

3 certain coverage; 

4 ‘‘(2) when the provider terminates a network 

5 agreement with a plan or with an issuer with respect 

6 to certain coverage; 

7 ‘‘(3) when there are material changes to the 

8 content of provider directory information described 

9 in subsection (a)(1); and 

10 ‘‘(4) every 90 days throughout the duration of 

11 the network agreement with a plan or issuer. 

12 ‘‘(d) ENFORCEMENT.— 

13 ‘‘(1) IN GENERAL.—Subject to paragraph (2), a 

14 health care provider that violates a requirement 

15 under subsection (c) or takes actions that prevent a 

16 group health plan or health insurance issuer from 

17 complying with subsection (a)(1) or (b) shall be sub18 ject to a civil monetary penalty of not more than 

19 $10,000 for each act constituting such violation. 

20 ‘‘(2) SAFE HARBOR.—The Secretary may waive 

21 the penalty described under paragraph (1) with re22 spect to a health care provider that unknowingly vio23 lates subsection (b)(1) with respect to an enrollee if 

24 such provider rescinds the bill involved and, if appli25 cable, reimburses the enrollee within 30 days of the 


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1 date on which the provider billed the enrollee in vio2 lation of such subsection. 

3 ‘‘(3) PROCEDURE.—The provisions of section 

4 1128A of the Social Security Act, other than sub5 sections (a) and (b) and the first sentence of sub6 section (c)(1) of such section, shall apply to civil 

7 money penalties under this subsection in the same 

8 manner as such provisions apply to a penalty or pro9 ceeding under section 1128A of the Social Security 

10 Act. 

11 ‘‘(e) SAVINGS CLAUSE.—Nothing in this section shall 

12 prohibit a provider from requiring in the terms of a con13 tract, or contract termination, with a group health plan 

14 or health insurance issuer— 

15 ‘‘(1) that the plan or issuer remove, at the time 

16 of termination of such contract, the provider from a 

17 directory of the plan or issuer described in sub18 section (a)(1); or 

19 ‘‘(2) that the plan or issuer bear financial re20 sponsibility, including under subsection (b), for pro21 viding inaccurate network status information to an 

22 enrollee. 

23 ‘‘(f) DEFINITION.—For purposes of this section, the 

24 term ‘provider directory information’ includes the names, 

25 addresses, specialty, and telephone numbers of individual 


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1 health care providers, and the names, addresses, and tele2 phone numbers of each medical group, clinic, or facility 

3 contracted to participate in any of the networks of the 

4 group health plan or health insurance coverage involved. 

5 ‘‘(g) RULE OF CONSTRUCTION.—Nothing in this sec6 tion shall be construed to preempt any provision of State 

7 law relating to health care provider directories or network 

8 adequacy.’’. 

9 (b) EFFECTIVE DATE.—Section 2729C of the Public 

10 Health Service Act, as added by subsection (a), shall take 

11 effect with respect to plan years beginning on or after the 

12 date that is 18 months after the date of enactment of this 

13 Act. 

14 SEC. 14. TIMELY BILLS FOR PATIENTS. 

15 (a) IN GENERAL.— 

16 (1) AMENDMENT.—Part P of title III of the 

17 Public Health Service Act (42 U.S.C. 280g et seq.) 

18 is amended by adding at the end the following: 

19 ‘‘SEC. 399V–7. TIMELY BILLS FOR PATIENTS. 

20 ‘‘(a) IN GENERAL.—The Secretary shall require— 

21 ‘‘(1) health care facilities, or in the case of 

22 practitioners providing services outside of such a fa23 cility, practitioners, to provide to patients a list of 

24 services rendered during the visit to such facility or 

25 practitioner, and, in the case of a facility, the name 


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1 of the provider for each such service, upon discharge 

2 or end of the visit or by postal or electronic commu3 nication as soon as practicable and not later than 5 

4 calendar days after discharge or date of visit; and 

5 ‘‘(2) health care facilities and practitioners to 

6 furnish all adjudicated bills to the patient as soon as 

7 practicable, but not later than 45 calendar days 

8 after discharge or date of visit. 

9 ‘‘(b) PAYMENT AFTER BILLING.—No patient may be 

10 required to pay a bill for health care services any earlier 

11 than 35 days after the postmark date of a bill for such 

12 services. 

13 ‘‘(c) EFFECT OF VIOLATION.— 

14 ‘‘(1) NOTIFICATION AND REFUND REQUIRE15 MENTS.— 

16 ‘‘(A) PROVIDER LISTS.—If a facility or 

17 practitioner fails to provide a patient a list as 

18 required under subsection (a)(1), such facility 

19 or practitioner shall report such failure to the 

20 Secretary. 

21 ‘‘(B) BILLING.—If a facility or practitioner 

22 bills a patient after the 45-calendar-day period 

23 described in subsection (a)(2), such facility or 

24 practitioner shall— 


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1 ‘‘(i) report such bill to the Secretary; 

2 and 

3 ‘‘(ii) refund the patient for the full 

4 amount paid in response to such bill with 

5 interest, at a rate determined by the Sec6 retary. 

7 ‘‘(2) CIVIL MONETARY PENALTIES.— 

8 ‘‘(A) IN GENERAL.—The Secretary may 

9 impose civil monetary penalties of up to 

10 $10,000 a day on any facility or practitioner 

11 that— 

12 ‘‘(i) fails to provide a list required 

13 under subsection (a)(1) more than 10 

14 times, beginning on the date of such tenth 

15 failure; 

16 ‘‘(ii) submits more than 10 bills out17 side of the period described in subsection 

18 (a)(2), beginning on the date on which 

19 such facility or practitioner sends the tenth 

20 such bill; 

21 ‘‘(iii) fails to report to the Secretary 

22 any failure to provide lists as required 

23 under paragraph (1)(A), beginning on the 

24 date that is 45 calendar days after dis25 charge or visit; or 


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1 ‘‘(iv) fails to send any bill as required 

2 under subsection (a)(2), beginning on the 

3 date that is 45 calendar days after the 

4 date of discharge or visit, as applicable. 

5 ‘‘(B) PROCEDURE.—The provisions of sec6 tion 1128A of the Social Security Act, other 

7 than subsections (a) and (b) and the first sen8 tence of subsection (c)(1) of such section, shall 

9 apply to civil money penalties under this sub10 section in the same manner as such provisions 

11 apply to a penalty or proceeding under section 

12 1128A of the Social Security Act. 

13 ‘‘(3) SAFE HARBOR.—The Secretary may ex14 empt a practitioner or facility from the penalties 

15 under paragraph (2)(A) or extend the period of time 

16 specified under subsection (a)(2) for compliance with 

17 such subsection if a practitioner or facility— 

18 ‘‘(A) makes a good-faith attempt to send a 

19 bill within 30 days but is unable to do so be20 cause of an incorrect address; or 

21 ‘‘(B) experiences extenuating cir22 cumstances (as defined by the Secretary), such 

23 as a hurricane or cyberattack, that may reason24 ably delay delivery of a timely bill.’’. 


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1 (2) RULEMAKING.—Not later than 1 year after 

2 the date of enactment of this Act, the Secretary 

3 shall promulgate final regulations to define the term 

4 ‘‘extenuating circumstance’’ for purposes of section 

5 399V–7(c)(3)(B) of the Public Health Service Act, 

6 as added by paragraph (1). 

7 (b) GROUP HEALTH PLAN AND HEALTH INSURANCE

8 ISSUER REQUIREMENTS.—Subpart II of part A of title 

9 XXVII of the Public Health Service Act (42 U.S.C. 

10 300gg–11), as amended by section 304, is further amend11 ed by adding at the end the following: 

12 ‘‘SEC. 2729D. TIMELY BILLS FOR PATIENTS. 

13 ‘‘(a) IN GENERAL.—A group health plan or health 

14 insurance issuer offering group or individual health insur15 ance coverage shall have in place business practices with 

16 respect to in-network facilities and practitioners to ensure 

17 that claims are adjudicated in order to facilitate facility 

18 and practitioner compliance with the requirements under 

19 section 399V–7(a). 

20 ‘‘(b) CLARIFICATION.—Nothing in subsection (a) pro21 hibits a provider and a group health plan or health insur22 ance issuer from establishing in a contract the timeline 

23 for submission by either party to the other party of billing 

24 information, adjudication, sending of remittance informa25 tion, or any other coordination required between the proVerDate Sep 11 2014 00:30 Sep 06, 2020 Jkt 099200 PO 00000 Frm 00059 Fmt 6652 Sfmt 6201 E:\BILLS\H8098.IH H8098

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1 vider and the plan or issuer necessary for meeting the 

2 deadline described in section 399V–7(a)(2).’’. 

3 (c) EFFECTIVE DATE.—The amendments made by 

4 subsections (a) and (b) shall take effect 6 months after 

5 the date of enactment of this Act. 

6 SEC. 15. GOVERNMENT ACCOUNTABILITY OFFICE STUDY 

7 ON PROFIT- AND REVENUE-SHARING IN 

8 HEALTH CARE. 

9 (a) STUDY.—Not later than 1 year after the date of 

10 enactment of this Act, the Comptroller General of the 

11 United States shall conduct a study to— 

12 (1) describe what is known about profit- and 

13 revenue-sharing relationships in the commercial 

14 health care markets, including those relationships 

15 that— 

16 (A) involve one or more— 

17 (i) physician groups that practice 

18 within a hospital included in the profit- or 

19 revenue-sharing relationship, or refer pa20 tients to such hospital; 

21 (ii) laboratory, radiology, or pharmacy 

22 services that are delivered to privately in23 sured patients of such hospital; 

24 (iii) surgical services; 


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1 (iv) hospitals or group purchasing or2 ganizations; or 

3 (v) rehabilitation or physical therapy 

4 facilities or services; and 

5 (B) include revenue- or profit-sharing 

6 whether through a joint venture, management 

7 or professional services agreement, or other 

8 form of gain-sharing contract; 

9 (2) describe Federal oversight of such relation10 ships, including authorities of the Department of 

11 Health and Human Services and the Federal Trade 

12 Commission to review such relationships and their 

13 potential to increase costs for patients, and identify 

14 limitations in such oversight; and 

15 (3) as appropriate, make recommendations to 

16 improve Federal oversight of such relationships. 

17 (b) REPORT.—Not later than 1 year after the date 

18 of enactment of this Act, the Comptroller General of the 

19 United States shall prepare and submit a report on the 

20 study conducted under subsection (a) to the Committee 

21 on Health, Education, Labor, and Pensions of the Senate 

22 and the Committee on Education and Labor and Com23 mittee on Energy and Commerce of the House of Rep24 resentatives. 


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1 SEC. 16. ENSURING ENROLLEE ACCESS TO COST-SHARING 

2 INFORMATION. 

3 (a) IN GENERAL.—Subpart II of part A of title 

4 XXVII of the Public Health Service Act (42 U.S.C. 

5 300gg–11 et seq.), as amended by section 306, is further 

6 amended by adding at the end the following: 

7 ‘‘SEC. 2729F. PROVISION OF COST-SHARING INFORMATION. 

8 ‘‘(a) PROVIDER DISCLOSURES.—A provider that is 

9 in-network with respect to a group health plan or a health 

10 insurance issuer offering group or individual health insur11 ance coverage shall provide to an enrollee in the plan or 

12 coverage who submits a request for the information de13 scribed in paragraph (1) or (2), together with accurate 

14 and complete information about the enrollee’s coverage 

15 under the applicable plan or coverage— 

16 ‘‘(1) as soon as practicable and not later than 

17 2 business days after the enrollee requests such in18 formation, a good faith estimate of the expected en19 rollee cost-sharing for the provision of a particular 

20 health care service (including any service that is rea21 sonably expected to be provided in conjunction with 

22 such specific service); and 

23 ‘‘(2) as soon as practicable and not later than 

24 2 business days after an enrollee requests such in25 formation, the contact information for any ancillary 

26 providers for a scheduled health care service. 


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1 ‘‘(b) INSURER DISCLOSURES.—A group health plan 

2 or a health insurance issuer offering group or individual 

3 health insurance coverage shall provide an enrollee in the 

4 plan or coverage with a good faith estimate of the enroll5 ee’s cost-sharing (including deductibles, copayments, and 

6 coinsurance) for which the enrollee would be responsible 

7 for paying with respect to a specific health care service 

8 (including any service that is reasonably expected to be 

9 provided in conjunction with such specific service), as soon 

10 as practicable and not later than 2 business days after 

11 a request for such information by an enrollee. 

12 ‘‘(c) ENFORCEMENT.— 

13 ‘‘(1) IN GENERAL.—Subject to paragraph (2), a 

14 health care provider that violates a requirement 

15 under subsection (a) shall be subject to a civil mone16 tary penalty of not more than $10,000 for each act 

17 constituting such violation. 

18 ‘‘(2) PROCEDURE.—The provisions of section 

19 1128A of the Social Security Act, other than sub20 sections (a) and (b) and the first sentence of sub21 section (c)(1) of such section, shall apply to civil 

22 money penalties under this subsection in the same 

23 manner as such provisions apply to a penalty or pro24 ceeding under section 1128A of the Social Security 

25 Act.’’. 


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1 (b) EFFECTIVE DATE.—Section 2729G of the Public 

2 Health Service Act, as added by subsection (a), shall apply 

3 with respect to plan years beginning on or after the date 

4 that is 18 months after the date of enactment of this Act. 

5 SEC. 17. GROUP HEALTH PLAN REPORTING REQUIRE6 MENTS. 

7 Part C of title XXVII of the Public Health Service 

8 Act (42 U.S.C. 300gg–91 et seq.), as amended by section 

9 303, is further amended by adding at the end the fol10 lowing: 

11 ‘‘SEC. 2797. GROUP HEALTH PLAN REPORTING. 

12 ‘‘(a) IN GENERAL.—A group health plan or health 

13 insurance issuer offering group or individual health insur14 ance coverage shall submit to the Secretary, not later than 

15 March 1 of each year, the following information with re16 spect to the health plan in the previous plan year: 

17 ‘‘(1) The beginning and end dates of the plan 

18 year. 

19 ‘‘(2) The number of enrollees. 

20 ‘‘(3) Each State in which the plan is offered. 

21 ‘‘(4) The 50 brand prescription drugs most fre22 quently dispensed by pharmacies for claims paid by 

23 the issuer, and the total number of paid claims for 

24 each such drug. 


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1 ‘‘(5) The 50 most costly prescription drugs with 

2 respect to the plan by total annual spending, and the 

3 annual amount spent by the plan for each such 

4 drug. 

5 ‘‘(6) The 50 prescription drugs with the great6 est increase in plan expenditures over the plan year 

7 preceding the plan year that is the subject of the re8 port, and, for each such drug, the change in 

9 amounts expended by the plan in each such plan 

10 year. 

11 ‘‘(7) Total spending on health care services by 

12 such group health plan, broken down by— 

13 ‘‘(A) the type of costs, including— 

14 ‘‘(i) hospital costs; 

15 ‘‘(ii) health care provider and clinical 

16 service costs; 

17 ‘‘(iii) costs for prescription drugs; and 

18 ‘‘(iv) other medical costs; and 

19 ‘‘(B) spending on prescription drugs by— 

20 ‘‘(i) the health plan; and 

21 ‘‘(ii) the enrollees. 

22 ‘‘(8) The average monthly premium— 

23 ‘‘(A) paid by employers on behalf of enroll24 ees; and 

25 ‘‘(B) paid by enrollees. 


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1 ‘‘(9) Any impact on premiums by rebates, fees, 

2 and any other remuneration paid by drug manufac3 turers to the plan or its administrators or service 

4 providers, with respect to prescription drugs pre5 scribed to enrollees in the plan, including— 

6 ‘‘(A) the amounts so paid for each thera7 peutic class of drugs; and 

8 ‘‘(B) the amounts so paid for each of the 

9 25 drugs that yielded the highest amount of re10 bates and other remuneration under the plan 

11 from drug manufacturers during the plan year. 

12 ‘‘(10) Any reduction in premiums and out-of13 pocket costs associated with rebates, fees, or other 

14 remuneration described in paragraph (9). 

15 ‘‘(b) REPORT.—Not later than 18 months after the 

16 date on which the first report is required under subsection 

17 (a) and biannually thereafter, the Secretary, acting 

18 through the Assistant Secretary of Planning and Evalua19 tion and in coordination with the Inspector General of the 

20 Department of Health and Human Services, shall make 

21 available on the internet website of the Department of 

22 Health and Human Services a report on prescription drug 

23 reimbursements under group health plans, prescription 

24 drug pricing trends, and the role of prescription drug costs 

25 in contributing to premium increases or decreases under 


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1 such plans, aggregated in such a way as no drug or plan 

2 specific information will be made public. 

3 ‘‘(c) PRIVACY PROTECTIONS.—No confidential or 

4 trade secret information submitted to the Secretary under 

5 subsection (a) shall be included in the report under sub6 section (b).’’. 

Æ 


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