II 116th CONGRESS 1st Session S. 1497 IN THE SENATE OF THE UNITED STATES May 15, 2019 Mr. Wyden introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend title XVIII of the Social Security Act to improve cost and quality transparency under the Medicare program, and for other purposes.

1. Short title This Act may be cited as the Health Care Price Check Act of 2019 . 2. Improving cost and quality transparency under the Medicare program (a) Secretary (1) In general Section 1804 of the Social Security Act ( 42 U.S.C. 1395b–2 ) is amended— (A) in subsection (b), in the first sentence, by striking The Secretary and inserting Subject to subsection (e)(1), the Secretary ; and (B) by adding at the end the following new subsection: (e) Cost and quality transparency (1) Requirements for toll-free telephone number Not later than 1 year after the date of the enactment of this Act (except as provided in subparagraph (A)(iv)), the Secretary shall ensure that the following information is available to an individual who calls the toll-free telephone number under subsection (b): (A) Costs The following information regarding costs for items and services under parts A and B: (i) The individual’s out-of-pocket costs for a specific item or service furnished by a specific provider of services or supplier. (ii) The payment amount under this title for such item or service furnished by such provider or supplier. (iii) The total allowable charges for such item or service furnished by such provider or supplier. (iv) Not later than 2 years after the date of the enactment of this Act, the information described in clauses (i) through (iii) for items and services that are frequently furnished together with the item or service described in such clauses, as determined by the Secretary. (v) An explanation of the cost-sharing components under parts A and B, including with respect to— (I) deductibles; (II) copayments; and (III) coinsurance. (B) Quality Quality information available through the Medicare Physician Compare, Hospital Compare, Nursing Home Compare, Dialysis Facility Compare, Inpatient Rehabilitation Facility Compare, Long-Term Care Hospital Compare, and Hospice Compare websites. (C) Additional information Other cost and quality information determined appropriate by the Secretary. (2) Internet website (A) In general Not later than 2 years after the date of the enactment of this Act, the Secretary shall ensure that an internet website is in place that meets the following requirements: (i) Search function Subject to clause (iv), the internet website contains a search function that enables an individual to search for an item or service in a geographic area— (I) by the type of item or service; and (II) by providers of services or suppliers, including both a general search and search by a specific name. (ii) Information The internet website is able to provide the information described in paragraph (1). (iii) Compare function The internet website contains a compare function that enables an individual to compare the out-of-pocket costs and quality for an item or service furnished by different providers of services or suppliers. (B) Limit The Secretary may limit the number of items and services for which information is available on the website but shall ensure that items and services which account for at least 50 percent of spending under parts A and B are included. (C) Existing website The Secretary may comply with the requirements under this paragraph through the use of an internet website that is in place as of the date of the enactment of this subsection. (3) Alert regarding estimates of costs The Secretary shall ensure that individuals receiving cost information under paragraph (1) or (2) are alerted that the information provided is an estimate and that the actual costs that the individual will be responsible for may vary. . (2) Funding There are appropriated to the Secretary of Health and Human Services such sums as the Secretary determines are necessary to carry out subsection (e) of section 1804 of the Social Security Act, as added by paragraph (1). (b) Medicare Advantage Section 1852 of the Social Security Act ( 42 U.S.C. 1395w–22 ) is amended— (1) in subsection (c), by adding at the end the following new paragraph: (3) Cost and quality transparency For plan year 2021 and subsequent plan years, subject to paragraph (4) of subsection (o), the Medicare Advantage organization shall comply with the requirements under such subsection). ; and (2) by adding at the end the following new subsection: (o) Cost and quality transparency (1) Toll-free telephone number (A) In general Each Medicare Advantage organization offering a Medicare Advantage plan shall have in place a toll-free telephone number under which enrollees in the plan that call the telephone number are able to receive the following information: (i) Costs for items and services The following information regarding costs for items and services under the plan: (I) The enrollee’s out-of-pocket costs for a specific item or service furnished by a specific in-network provider of services or supplier. (II) The information described in subclause (I) for items and services that are frequently furnished together with the item or service described in such subclause, as determined by the Secretary. (III) An explanation of the cost-sharing components, both generally and under the plan specifically, including with respect to— (aa) deductibles; (bb) copayments; and (cc) coinsurance. (ii) Costs for covered part D drugs In the case of an MA–PD plan, the information described in section 1860D–4(o)(1)(A). (iii) Quality Information on the quality of items and services furnished by providers of services and suppliers under the plan, as determined appropriate by the Secretary. (iv) Out-of-network providers If an enrollee of the plan requests information on an out-of-network provider of services or supplier,— (I) information on the out-of-network benefits offered under the plan; and (II) other information, as determined appropriate by the Secretary. (v) Additional information Other cost and quality information determined appropriate by the Secretary. (B) Access The toll-free telephone number under subparagraph (A) shall be accessible by calling a number directly or by charge-free transfer pursuant to section 1804(b). (C) Integration with existing telephone number The requirements for a toll-free telephone number under subparagraph (A) may be provided through an existing enrollee toll-free telephone number. (2) Internet website (A) In general Subject to clause (iv), each Medicare Advantage organization offering a Medicare Advantage plan shall have in place an internet website that meets the following requirements: (i) Search function The internet website contains a search function that enables an enrollee to search— (I) for an item or service in a geographic area— (aa) by the type of item or service; and (bb) by providers of services or suppliers; and (II) in the case of an MA–PD plan, for a covered part D drug under the plan. (ii) Information The internet website is able to provide the information described in— (I) paragraph (1)(A); and (II) in the case of an MA–PD plan, section 1860D–4(o)(1)(A). (iii) Compare function The internet website contains a compare function that enables an enrollee to compare— (I) the out-of-pocket costs and quality for an item or service furnished by different providers of services or suppliers; and (II) in the case of an MA–PD plan, each of subclauses (I) and (II) of section 1860D–4(o)(2)(A)(iii) for a covered part D drug. (iv) Limit A Medicare Advantage organization may limit the number of items and services for which information is available on the website pursuant to the limits established by the Secretary under section 1804(e)(2)(A)(iv). (B) Integration with existing internet website If a Medicare Advantage organization offering a Medicare Advantage plan has in place an internet website for the plan as of the date of the enactment of this subsection, the organization shall integrate the requirements under subparagraph (A) into such website, including through the same log-in process as the existing website. (C) Link to an external internet website for information on covered part D drugs A Medicare Advantage organization offering a Medicare Advantage plan may provide the information described subparagraph (A)(ii)(II) for the plan through a link on the plan's internet website to an external internet website. (3) Alert regarding estimates of costs Each Medicare Advantage organization offering a Medicare Advantage plan shall ensure that enrollees of the plan receiving cost information under paragraph (1) or (2) are alerted that the information provided is an estimate and that the actual costs that the enrollee will be responsible for may vary. (4) Exemption The requirements of this subsection shall not apply to a Medicare Advantage organization if the total number of enrollees in all the Medicare Advantage plans offered by the organization is less than a number of enrollees determined appropriate by the Secretary. . (c) Prescription drug plans Section 1860D–4 of the Social Security Act ( 42 U.S.C. 1395w–104 ) is amended— (1) by redesignating the subsection (m) as added by section 6063(c) of the SUPPORT for Patients and Communities Act ( Public Law 115–271 ) as subsection (n); and (2) by adding at the end the following new subsection: (o) Cost transparency For plan year 2021 and subsequent plan years, subject to paragraph (4), each PDP sponsor offering a prescription drug plan shall comply with the following: (1) Toll-free telephone number (A) In general The PDP sponsor offering the prescription drug plan shall have in place a toll-free telephone number under which enrollees in the plan that call the telephone number are able to receive the following information: (i) The enrollee’s out-of-pocket costs for a specific covered part D drug filled by a specific in-network pharmacy. (ii) An explanation of the cost-sharing components for covered part D drugs, both generally and under the plan specifically, including with respect to— (I) deductibles; (II) copayments; and (III) coinsurance. (B) Integration with existing telephone number The requirements for a toll-free telephone number under subparagraph (A) may be provided through an existing enrollee toll-free telephone number. (2) Internet website (A) In general Each PDP sponsor offering a prescription drug plan shall have in place an internet website that meets the following requirements: (i) Search function The internet website contains a search function that enables an enrollee to search for a covered part D drug under the plan. (ii) Information The internet website is able to provide the information described in subparagraph (A) of paragraph (1). (iii) Compare function The internet website contains a compare function that enables an enrollee to compare each of the following for a covered part D drug: (I) The out-of-pocket costs for multiple pharmacies, including mail order if available. (II) The out-of-pocket costs for clinically equivalent therapeutic options, including but not limited to generic alternatives. (B) Integration with existing internet website If a PDP sponsor offering a prescription drug plan has in place an internet website for the plan as of the date of the enactment of this subsection, the organization shall integrate the requirements under subparagraph (A) into such website, including through the same log-in process as the existing website. (C) Link to an external internet website A PDP sponsor offering a prescription drug plan may provide the information described subparagraph (A)(ii) for the plan through a link on the plan's internet website to an external internet website. (3) Alert regarding estimates of costs Each PDP sponsor offering a prescription drug plan shall ensure that enrollees of the plan receiving cost information under paragraph (1) or (2) are alerted that the information provided is an estimate and that the actual costs that the enrollee will be responsible for may vary. (4) Exemption The requirements of this subsection shall not apply to a PDP sponsor if the total number of enrollees in all the prescription drug plans offered by the sponsor is less than a number of enrollees determined appropriate by the Secretary. . 3. Improving cost and quality transparency under private health insurance (a) In general Title XXVII of the Public Health Service Act is amended by inserting after section 2715A ( 42 U.S.C. 300gg–15a ) the following: 2715B. Improving cost and quality transparency under private health insurance (a) Toll-Free telephone number (1) In general A group health plan and a health insurance issuer offering group or individual health insurance coverage shall have in place a toll-free telephone number under which enrollees in the plan or coverage calling the telephone number are able to receive, directly or through charge-free transfer, information regarding the quality of in-network providers and facilities, as defined by the Secretary, and the following information regarding out-of-pocket costs for benefits under the plan or coverage: (A) The enrollee’s out-of-pocket costs for a specific covered benefit provided by a specific in-network provider or facility, and other covered benefits frequently associated with the specific covered benefit, as determined by the Secretary. (B) An explanation of the cost-sharing components under the applicable plan or coverage, including with respect to— (i) deductibles; (ii) copayments; and (iii) coinsurance. (C) With respect to prescription drugs covered by the plan or coverage— (i) out-of-pocket costs; (ii) variation in the costs, coverage, and prices described in clause (i) by pharmacy options, including the preferred pharmacy, mail order pharmacy (if applicable), and other pharmacies in the designated geographic area; and (iii) variation in such costs with respect to generic or other therapeutically equivalent alternatives. (D) With respect to services provided by an out-of-network provider, a summary of the out-of-network benefits offered under the plan or coverage, and other information determined appropriate by the Secretary; and (E) Other information determined appropriate by the Secretary. (2) Integration with existing services The requirements for a toll-free telephone number under paragraph (1) may be provided through an existing enrollee toll-free telephone number. (3) Prescription drug information A group health plan or health insurance issuer that has a contract with another entity offering prescription drug management services with respect to the plan or applicable health insurance coverage may satisfy the requirement to provide the information required under paragraph (1)(C) by connecting enrollees to a toll-free telephone service of such entity where such entity makes such information available. (b) Internet website (1) In general A group health plan and a health insurance issuer offering group or individual health insurance coverage shall have in place an internet website that meets the following requirements with respect to providing enrollees with information regarding the quality of in-network providers and facilities, as defined by the Secretary, and information on out-of-pocket costs for benefits under the plan or coverage: (A) Search function The internet website contains a search function that enables an enrollee to search for a benefit in a geographic area, at minimum— (i) by the type of benefit; and (ii) by providers in the area. (B) Costs The internet website is able to provide the following information: (i) The enrollee’s out-of-pocket costs for a specific benefit provided by a specific in-network provider, and other covered benefits frequently associated with the specific covered benefit, as determined by the Secretary. (ii) An explanation of the cost-sharing components, under the applicable plan or coverage specifically, including with respect to— (I) deductibles; (II) copayments; and (III) coinsurance. (iii) With respect to prescription drugs covered by the plan or coverage— (I) out-of-pocket costs; (II) variation in the costs described in subclause (I) by pharmacy options, including the preferred pharmacy, mail order pharmacy (if applicable), and other pharmacies in the designated geographic area; and (III) variation in such costs, coverage, and prices with respect to generic or other therapeutically equivalent alternatives. (iv) With respect to services provided by an out-of-network provider, a summary of the out-of-network benefits offered under the plan or coverage, and other information determined appropriate by the Secretary; and (v) Other information determined appropriate by the Secretary. (C) Compare function The internet website contains a compare function that enables an enrollee to compare the out-of-pocket costs and quality measures for a benefit furnished by different providers. (2) Integration If a group health plan or health insurance issuer has in place an internet website for enrollees in a plan or coverage as of the date of the enactment of this section, the plan or issuer shall integrate the requirements under paragraph (1) into such website, including through the same log-in process as the existing website. (3) Extent of information A group health plan or health insurance issuer may limit the number of health care services for which the information required under paragraph (1)(B) is available on the website to a number determined by the Secretary. (4) Prescription drug information A group health plan or health insurance issuer that has a contract with another entity offering prescription drug management services with respect to the plan or applicable health insurance coverage may satisfy the requirement to provide the information required under paragraph (1)(B)(iii) by providing a link to the internet website of such entity where such entity makes such information available. (c) Disclosure requirement A group health plan or health insurance issuer shall inform enrollees seeking information through the toll-free telephone number under subsection (a) or the internet website under subsection (b) that the cost information provided are estimates and that the actual amount the enrollee will be responsible for paying may vary. (d) Regulations The Secretary, in consultation with the Administrator of the Centers for Medicare & Medicaid Services, shall promulgate regulations to carry out this section in a manner similar to the requirements for out-of-pocket cost transparency applicable to Medicare Advantage organizations under section 1852(o) of the Social Security Act. (e) Exemption The requirements of this section shall not apply to a small or regional group health plan, or to a small or regional health insurance issuer with respect to health insurance coverage. The Secretary shall define small or regional group health plan and small or regional health insurance issuer for purposes of this subsection. . (b) Effective date Section 2715A of the Public Health Service Act, as added by subsection (a), shall take effect on January 1, 2021.