Promoting Transparency and Healthy Competition in Medicare Act

Subjects: Health


<html><body><pre>[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3282 Introduced in House (IH)]

&lt;DOC&gt;






118th CONGRESS
  1st Session
                                H. R. 3282

To amend title XVIII of the Social Security Act to promote transparency 
   of common ownership interests under parts C and D of the Medicare 
                                program.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                              May 15, 2023

  Mrs. Harshbarger (for herself, Ms. Schrier, Mr. Bilirakis, and Ms. 
 Schakowsky) introduced the following bill; which was referred to the 
Committee on Ways and Means, and in addition to the Committee on Energy 
    and Commerce, for a period to be subsequently determined by the 
  Speaker, in each case for consideration of such provisions as fall 
           within the jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL


 
To amend title XVIII of the Social Security Act to promote transparency 
   of common ownership interests under parts C and D of the Medicare 
                                program.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Promoting Transparency and Healthy 
Competition in Medicare Act''.

SEC. 2. PROMOTING TRANSPARENCY OF COMMON OWNERSHIP INTERESTS UNDER 
              PARTS C AND D OF THE MEDICARE PROGRAM.

    (a) Medicare Advantage.--Section 1857(e) of the Social Security Act 
(42 U.S.C. 1395w-27(e)) is amended by adding at the end the following 
new paragraph:
            ``(6) Required disclosure of certain information relating 
        to health care provider ownership.--
                    ``(A) In general.--For plan years beginning on or 
                after January 1, 2025, a contract under this section 
                with an MA organization shall require the organization 
                to report to the Secretary, not later than 1 year after 
                the last day of such plan year, the information 
                described in subparagraph (B) with respect to such plan 
                year.
                    ``(B) Information described.--For purposes of 
                subparagraph (A), the information described in this 
                subparagraph is, with respect to an MA organization and 
                a plan year, the following:
                            ``(i) The number of items and services 
                        furnished during such plan year by each 
                        specified provider (as defined in subparagraph 
                        (C)) for which payment was made by such 
                        organization.
                            ``(ii) The number of items and services 
                        furnished during such plan year by providers of 
                        services or suppliers not described in clause 
                        (i) for which payment was made by such 
                        organization.
                            ``(iii) The average per-enrollee number of 
                        qualifying diagnoses (as defined in 
                        subparagraph (C)) made during such plan year by 
                        specified providers (including through chart 
                        reviews and health risk assessments) with 
                        respect to individuals enrolled under an MA 
                        plan offered by such organization, broken down 
                        by site of service of such providers, as 
                        specified by the Secretary.
                            ``(iv) The average per-enrollee number of 
                        qualifying diagnoses made during such plan year 
                        by providers of services and suppliers not 
                        described in clause (iii) (including through 
                        such reviews and assessments) with respect to 
                        such individuals, broken down by site of 
                        service of such providers.
                            ``(v) The average risk score (as calculated 
                        under the methodology described in subparagraph 
                        (C)(i)) for such an individual for such plan 
                        year who received items and services from a 
                        specified provider during such plan year.
                            ``(vi) The average risk score for such an 
                        individual for such plan year who did not 
                        receive items and services from a specified 
                        provider during such plan year.
                            ``(vii) The average risk score for such an 
                        individual for such plan year who received a 
                        health risk assessment from an assessment 
                        entity that was a specified assessment entity 
                        during such plan year.
                            ``(viii) The average risk score for such an 
                        individual for such plan year who received a 
                        health risk assessment from an assessment 
                        entity that was not a specified assessment 
                        entity during such plan year.
                            ``(ix) The number of prior authorization 
                        requests for an item or service submitted to 
                        such organization during such plan year, the 
                        number of such requests that were approved, the 
                        number of such requests that were denied, and 
                        the number of such denied requests that were 
                        subsequently appealed and then approved, broken 
                        down by whether the entity proposing to furnish 
                        such item or service was a specified provider 
                        or not a specified provider.
                            ``(x) The total amount of incentive-based 
                        payments made to, and the total amount of 
                        shared losses recoupments collected from, 
                        specified providers during such plan year.
                            ``(xi) The total amount of incentive-based 
                        payments made to, and the total amount of 
                        shared losses recoupments collected from, 
                        providers of services and suppliers not 
                        described in clause (x) during such plan year.
                            ``(xii) For each MA plan offered by such 
                        organization during such plan year--
                                    ``(I) the total amount of payments 
                                made under section 1853(a)(1) to such 
                                organization for coverage of 
                                individuals under such plan, and the 
                                total amount of payments made by such 
                                individuals to such organization for 
                                coverage under such plan;
                                    ``(II) the total amount expended 
                                under such plan as payment for items 
                                and services furnished by each 
                                specified provider during such year;
                                    ``(III) the total amount expended 
                                under such plan as payment for items 
                                and services furnished by providers of 
                                services or suppliers not described in 
                                subclause (II) during such year;
                                    ``(IV) the medical loss ratio under 
                                such plan with respect to individuals 
                                furnished an item or service from a 
                                specified provider during such year; 
                                and
                                    ``(V) the medical loss ratio under 
                                such plan with respect to individuals 
                                not described in subclause (IV).
                    ``(C) Definitions.--In this paragraph:
                            ``(i) Assessment entity.--The term 
                        `assessment entity' means an entity with a 
                        focus on furnishing in-home medical 
                        assessments, as specified by the Secretary.
                            ``(ii) Qualifying diagnosis.--The term 
                        `qualifying diagnosis' means, with respect to 
                        an individual, a diagnosis that is taken into 
                        account in calculating a risk score for such 
                        individual under the risk adjustment 
                        methodology established by the Secretary 
                        pursuant to section 1853(a)(3).
                            ``(iii) Specified assessment entity.--The 
                        term `specified assessment entity' means, with 
                        respect to an MA organization and a plan year, 
                        an assessment entity with respect to which such 
                        organization (or any person with an ownership 
                        or control interest (as defined in section 
                        1124(a)(3)) in such organization) is a person 
                        with an ownership or control interest (as so 
                        defined).
                            ``(iv) Specified provider.--The term 
                        `specified provider' means, with respect to an 
                        MA organization and a plan year, a provider of 
                        services or supplier with respect to which such 
                        organization (or any person with an ownership 
                        or control interest (as defined in section 
                        1124(a)(3)) in such organization) is a person 
                        with an ownership or control interest (as so 
                        defined).
                    ``(D) Nonapplication of paperwork reduction act.--
                Chapter 35 of title 44, United States Code, shall not 
                apply to information collected under this paragraph.''.
    (b) Pharmacy Benefit Manager and Pharmacy Information.--Section 
1860D-12(b) of the Social Security Act (42 U.S.C. 1395w-112(b)) is 
amended by adding at the end the following new paragraphs:
            ``(9) Provision of information relating to pharmacy 
        ownership.--
                    ``(A) In general.--For plan years beginning on or 
                after January 1, 2025, a contract entered into under 
                this part with a PDP sponsor shall require the sponsor 
                to report to the Secretary, not later than 1 year after 
                the last day of such plan year, the information 
                described in subparagraph (B) with respect to such plan 
                year.
                    ``(B) Information described.--For purposes of 
                subparagraph (A), the information described in this 
                subparagraph is, for each prescription drug plan 
                offered by a PDP sponsor for a plan year, the 
                following:
                            ``(i) The negotiated price for each covered 
                        part D drug for which benefits are available 
                        under such plan for each network pharmacy 
                        (including an identification of whether each 
                        such pharmacy is a specified pharmacy).
                            ``(ii) The average per-drug amount of 
                        direct and indirect remuneration paid by 
                        specified pharmacies for such covered part D 
                        drugs dispensed during such plan year under 
                        such plan.
                            ``(iii) The average per-drug amount of 
                        direct and indirect remuneration paid by 
                        pharmacies not described in clause (ii) for 
                        such covered part D drugs dispensed during such 
                        plan year under such plan.
                    ``(C) Definitions.--In this paragraph:
                            ``(i) Direct and indirect remuneration.--
                        The term `direct and indirect remuneration' has 
                        the meaning given such term in section 423.308 
                        of title 42, Code of Federal Regulations (or 
                        any successor regulation).
                            ``(ii) Network pharmacy.--The term `network 
                        pharmacy' has the meaning given such term in 
                        section 423.100 of title 42, Code of Federal 
                        Regulations (or any successor regulation).
                            ``(iii) Negotiated price.--The `negotiated 
                        price' for a covered part D drug shall take 
                        into account all negotiated price concessions, 
                        such as discounts, direct or indirect 
                        subsidies, rebates, and direct or indirect 
                        remunerations, for such drug, and include any 
                        dispensing fee for such drug.
                            ``(iv) Specified pharmacy.--The term 
                        `specified pharmacy' means, with respect to an 
                        PDP sponsor and a plan year, a pharmacy with 
                        respect to which such sponsor (or any person 
                        with an ownership or control interest (as 
                        defined in section 1124(a)(3)) in such sponsor) 
                        is a person with an ownership or control 
                        interest (as so defined).
                    ``(D) Nonapplication of paperwork reduction act.--
                Chapter 35 of title 44, United States Code, shall not 
                apply to information collected under this paragraph.
            ``(10) Provision of information by pharmacy benefit 
        managers.--
                    ``(A) In general.--For plan years beginning on or 
                after January 1, 2025, a contract entered into under 
                this part with a PDP sponsor shall prohibit such 
                sponsor from entering into a contract with a specified 
                pharmacy benefit manager for purposes of performing any 
                service with respect to covered part D drugs dispensed 
                under any prescription drug plan offered by such 
                sponsor for such plan year unless such manager agrees 
                to report to the Secretary, not later than 1 year after 
                the last day of such plan year, the information 
                described in subparagraph (B) with respect to each 
                prescription drug plan for which such manager is 
                providing any such service during such plan year, 
                regardless of the sponsor of such plan.
                    ``(B) Information described.--For purposes of 
                subparagraph (A), the information described in this 
                subparagraph is, with respect to a pharmacy benefit 
                manager performing services under a prescription drug 
                plan for a plan year, the following:
                            ``(i) With respect to the total amount of 
                        pharmacy and manufacturer rebates collected by 
                        such manager (or collected on behalf of such 
                        plan by any other entity with a contract in 
                        effect with such manager for such collection) 
                        for all covered part D drugs dispensed under 
                        such plan during such plan year--
                                    ``(I) the total amount of such 
                                rebates passed through to the PDP 
                                sponsor of such plan; and
                                    ``(II) the total amount of such 
                                rebates retained by such manager or 
                                such other entities.
                            ``(ii) The total amount paid by such 
                        manager to pharmacies for drugs furnished under 
                        such plan during such plan year.
                            ``(iii) The total amount of payments made 
                        by such sponsor to such manager as 
                        reimbursement for such manager's payments 
                        described in clause (ii).
                            ``(iv) The total amount of payments made by 
                        such sponsor to such manager as fees for 
                        services furnished by such manager with respect 
                        to such plan for such plan year (not including 
                        payments described in clause (iii)).
                            ``(v) The total amount of administrative 
                        costs incurred by such manager for furnishing 
                        such services under such plan for such plan 
                        year.
                            ``(vi) A specification as to whether such 
                        manager is a specified pharmacy benefit manager 
                        with respect to the PDP sponsor of such plan.
                    ``(C) Definition.--In this paragraph, the term 
                `specified pharmacy benefit manager' means, with 
                respect to an PDP sponsor and a plan year, a pharmacy 
                benefit manager with respect to which such sponsor (or 
                any person with an ownership or control interest (as 
                defined in section 1124(a)(3)) in such sponsor) is a 
                person with an ownership or control interest (as so 
                defined).''.
    (c) Publication.--Not later than January 1, 2027, the Secretary of 
Health and Human Services shall establish a process under which 
information submitted to the Secretary pursuant to the amendments made 
by this section is publicly disclosed. Such process shall ensure that 
any information so disclosed does not identify a specific drug 
manufacturer, provider of services or supplier, pharmacy, pharmacy 
benefit manager, or any price charged with respect to a particular 
drug.
                                 &lt;all&gt;
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