Short title

This Act may be cited as the

Hospital Competition Act of 2020

Hospital consolidation

(a)

Authorization of appropriations

There is authorized to be appropriated $160,000,000 to the Federal Trade Commission to hire staff to investigate, as consistent with the Sherman Antitrust Act and other relevant Federal laws, anti-competitive mergers and practices under such laws to the extent such mergers and practices relate to providers of inpatient and outpatient health care services, as defined by the Secretary of Health and Human Services. (b)

Medicare Advantage rates applied to certain HHI hospitals

(1)

In general

Section 1866(a) of the Social Security Act (42 U.S.C. 1395cc(a)) is amended— (A)in paragraph (1)— (i)in subparagraph (X), by striking and at the end; (ii)in subparagraph (Y), by striking the period at the end and inserting ; and; and (iii)by inserting after subparagraph (Y) the following new subparagraph:

(Z)subject to paragraph (4), in the case of a hospital located in a county whose population density is above the median population density for all counties in the United States with respect to which there is a Herfindahl-Hirschman Index (HHI) of greater than 4,000, to apply the average reimbursement rate with respect to individuals (regardless of whether such an individual is entitled to or eligible for benefits under this title, but excluding individuals eligible for medical assistance under a State plan under title XIX) furnished items and services at such hospital that would be billable under this title for such items and services if furnished by such hospital to an individual enrolled under part C.

; and

(B)by adding at the end the following new paragraph:

(4) (A)The requirement under paragraph (1)(Z) shall not apply in the case of a hospital in a hospital referral region if— (i)the HRR market share of such hospital (as determined under subparagraph (B)) is less than 0.15; or (ii)the hospital is located in a rural area (as defined in section 1886(d)(2)(D)); (B)For purposes of subparagraph (A), the HRR market share of a hospital in a hospital referral region is equal to— (i)the total revenue of the hospital, divided by (ii)the total revenue of all hospital in the hospital referral region.

(2)

Effective date

The amendments made by this subsection shall apply with respect to items and services furnished on or after January 1, 2021. (c)

Grants for hospital infrastructure improvement

(1)

In general

The Secretary of Health and Human Services shall carry out a grant program under which the Secretary shall provide grants to eligible States, in accordance with this subsection. (2)

Uses

An eligible State receiving a grant under this subsection may use such grant to improve the State hospital infrastructure and to supplement any other funds provided for a purpose authorized under a State or local hospital grant programs under State law. (3)

Eligibility

(A)

In general

An eligible State may receive not more than one grant under this subsection with respect to each qualifying criterion described in subparagraph (B) that is met by the State. (B)

Eligible State

For purposes of this subsection, the term eligible State means a State that meets any one or more of the following qualifying criteria: (i)The State does not have in effect any State certificate of need law that requires a health care provider to provide to a regulatory body a certification that the community needs the services provided by the health care provider. (ii)The State has in effect State scope of practice laws that— (I)allow advanced practice providers (such as nurse practitioners, advanced practice registered nurses, clinical nurse specialists, and physician assistants) to evaluate patients; diagnose, order, and interpret diagnostic tests; and initiate and manage treatments; or (II)provide that the only justification for limiting the scope of practice of a health care provider is safety to the public. (iii)The State does not have in effect any State laws that require managed care plans to accept into the network of such plan any qualified provider who is willing to accept the terms and conditions of the managed care plan. (iv)The State does not have in effect any Certificate of Public Advantage laws that clearly articulate the State’s intent to displace competition in favor of regulation or that violate State or Federal antitrust laws. (v)The State does not have in effect any network adequacy laws regulating a health plan’s ability to deliver benefits by providing reasonable access to a sufficient number of in-network primary care and specialty physicians, as well as all health care services included under the terms of an insuree’s contract with a health insurer. (4)

Funding

There is authorized to be appropriated to carry out this subsection $1,000,000,000 for each of the fiscal years 2021 through 2030. Funds appropriated under this paragraph shall remain available until expended. (d)

Critical access hospital reimbursement rates

(1)

Part A

Section 1814(l)(1) of the Social Security Act (42 U.S.C. 1395f(l)(1)) is amended by inserting (or, for 2021, 102, plus 1 percentage point for each subsequent year through 2029, and 110 for each subsequent year thereafter) after 101. (2)

Part B

Section 1834(g)(1) of such Act (42 U.S.C. 1395m(g)(1)) is amended by inserting (or, for 2021, 102, plus 1 percentage point for each subsequent year through 2029, and 110 for each subsequent year thereafter) after 101.

Price transparency

Section 1866 of the Social Security Act (42 U.S.C. 1395cc), as amended by section 401, is further amended— (1)in subsection (a)(1)— (A)in subparagraph (Y), by striking and at the end; (B)in subparagraph (Z), by striking the period at the end and inserting ; and; and (C)by inserting after subparagraph (Z) the following new subparagraph:

(AA)in the case of a hospital, to comply with the requirement under subsection (l).

; and

(2)by adding at the end the following new subsection:

(l)

Requirement relating to publishing certain hospital prices

(1)

In general

For purposes of subsection (a)(1)(AA), the requirement described in this subsection is, with respect to a hospital and year (beginning with 2021), for the hospital to publicly post, through the system established under paragraph (3), for each commonly shoppable service included in the list published under paragraph (2) for such year, the volume-weighted average price charged by the hospital to— (A)individuals enrolled during such year in group health plans or health insurance coverage offered in the individual or group market (as such terms are defined in section 2791 of the Public Health Service Act); and (B)individuals who are not enrolled in any health insurance coverage or health benefits plan and individuals who are enrolled in such coverage or plan but such coverage or plan does not provide benefits for the service. (2)

Commonly shoppable services

For purposes of subsection (a)(1)(AA) and this subsection, the Secretary shall, for 2021 and each subsequent year, publish a list of the 100 commonly shoppable services that are the most highly utilized in a hospital-based setting. (3)

Standardized digital reporting system

Not later than January 1, 2021, the Secretary shall establish a standardized digital system for purposes of paragraph (1).

Repealing eligibility of certain ACOs

(a)

In general

Section 1899(b)(1) of the Social Security Act (42 U.S.C. 1395jjj(b)(1)) is amended by striking subparagraphs (C) through (E). (b)

Effective date

The amendment made by subsection (a) shall take effect on January 1, 2021.

Off-campus provider-based department medicare site neutral payment

(a)

In general

Section 1834 of the Social Security Act (42 U.S.C. 1395m) is amended by adding at the end the following new subsection:

(x)

Off-Campus provider-Based department site neutral payment

(1)

In general

With respect to items and services furnished in an off-campus provider-based department, payment under this section for such items and services shall be the amount determined under the fee schedule under section 1848 for such items and services furnished if furnished in a physician office setting. (2)

Off-campus provider-based department

For purposes of this subsection, the term off-campus provider-based department has such meaning as specified by the Secretary.

(b)

Effective date

The amendment made by subsection (a) shall apply with respect to items and services furnished on or after January 1, 2021.

Repeal of health care reform provisions limiting Medicare exception to the prohibition on certain physician referrals for hospitals

Sections 6001 and 10601 of the Patient Protection and Affordable Care Act (Public Law 111–148; 124 Stat. 684, 1005) and section 1106 of the Health Care and Education Reconciliation Act of 2010 (Public Law 111–152; 124 Stat. 1049) are repealed and the provisions of law amended by such sections are restored as if such sections had never been enacted.

Advisory group on reducing burden of hospital administrative requirements

(a)

In general

Not later than January 1, 2021, the Secretary of Health and Human Services shall convene an advisory group to provide, in accordance with this section, recommendations on ways the Federal Government could reduce the burden of administrative requirements on hospitals. (b)

Recommendations

Not later than January 1, 2022, the advisory board convened under this section shall— (1)submit to the Secretary of Health and Human Services recommendations described under subsection (a) for executive action and any recommendations for State actions for potential consideration in making grants under section 2(c) to States; and (2)submit to Congress recommendations described under subsection (a) for legislative proposals. (c)

Membership

The advisory board under this section shall consist of the following members: (1)Three representatives of companies that have— (A)geographically distributed workforces; (B)at least 10,000 employees; and (C)no more than 10 percent of such employees in any single State. (2)Three representatives of health insurance issuers and health plans, consisting of— (A)one representative of for-profit health insurance issuers and health plans with at least 20,000,000 enrollees in the employer-sponsored market; (B)one representative of non-profit health insurance issuers and health plans operating in at least 5 States; and (C)one representative of non-profit health insurance issuers and health plans operating in a rural State (as defined by the Census Bureau). (3)Seven public policy experts in the field of hospital consolidation.

Authority of Federal Trade Commission over certain tax-exempt organizations

Section 4 of the Federal Trade Commission Act (15 U.S.C. 44) is amended, in the undesignated paragraph relating to the definition of the term Corporation— (1)by striking , and any and inserting , any; and (2)by inserting before the period at the end the following: , and any organization described in section 501(c)(3) of the Internal Revenue Code of 1986 that is exempt from taxation under section 501(a) of such Code.

Leveling the playing field between providers and payers

(a)

Exemption

It shall not be a violation of the antitrust laws for one or more private health insurer issuers or their designated agents to jointly negotiate prices of particular hospital services with a hospital provider with regards to the reimbursement policies of the insurers for those services. (b)

Definitions

For purposes of this section: (1)

Antitrust laws

The term antitrust laws has the meaning given it in subsection (a) of the 1st section of the Clayton Act (15 U.S.C. 12(a)), except that such term includes section 5 of the Federal Trade Commission Act (15 U.S.C. 45) to the extent such section 5 applies to unfair methods of competition. (2)

Health insurance issuer

The term health insurance issuer means an insurance company, insurance service, or insurance organization (including a health maintenance organization, as defined in subparagraph (C)) which is licensed to engage in the business of insurance in a State and which is subject to State law which regulates insurance (within the meaning of section 514(b)(2) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1144(b)(2)). Such term does not include a group health plan. (3)

Health maintenance organization

The term health maintenance organization means— (A)a federally qualified health maintenance organization (as defined in section 300e(a) of title 42 of the Code of Federal Regulations), (B)an organization recognized under State law as a health maintenance organization, or (C)a similar organization regulated under State law for solvency in the same manner and to the same extent as such a health maintenance organization. (c)

Effective date

This section shall take effect on the date of the enactment of this Act but shall not apply with respect to conduct that occurs before such date.

10.

Increasing transparency by removing gag clauses on price and quality information

Subpart II of part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–11 et seq.), as amended by section 103, is amended by adding at the end the following:

2729B.

Increasing transparency by removing gag clauses on price and quality information

(a)

Increasing price and quality transparency for plan sponsors and group and individual market and consumers

(1)

Group health plans

A group health plan or health insurance issuer offering group health insurance coverage may not enter into an agreement with a health care provider, network or association of providers, third-party administrator, or other service provider offering access to a network of providers that would directly or indirectly restrict a group health plan or health insurance issuer from— (A)providing provider-specific cost or quality of care information, through a consumer engagement tool or any other means, to referring providers, the plan sponsor, enrollees, or eligible enrollees of the plan or coverage; (B)electronically accessing de-identified claims and encounter data for each enrollee in the plan or coverage, upon request and consistent with the privacy regulations promulgated pursuant to section 264(c) of the Health Insurance Portability and Accountability Act, the amendments to this Act made by the Genetic Information Nondiscrimination Act of 2008, and the Americans with Disabilities Act of 1990, with respect to the applicable health plan or health insurance coverage, including, on a per claim basis— (i)financial information, such as the allowed amount, or any other claim-related financial obligations included in the provider contract; (ii)provider information, including name and clinical designation; (iii)service codes; or (iv)any other data element normally included in claim or encounter transactions when received by a plan or issuer; or (C)sharing data described in subparagraph (A) or (B) with a business associate as defined in section 160.103 of title 45, Code of Federal Regulations (or successor regulations), consistent with the privacy regulations promulgated pursuant to section 264(c) of the Health Insurance Portability and Accountability Act, the amendments to this Act made by the Genetic Information Nondiscrimination Act of 2008, and the Americans with Disabilities Act of 1990. (2)

Individual health insurance coverage

A health insurance issuer offering individual health insurance coverage may not enter into an agreement with a health care provider, network or association of providers, or other service provider offering access to a network of providers that would directly or indirectly restrict the health insurance issuer from— (A)providing provider-specific price or quality of care information, through a consumer engagement tool or any other means, to referring providers, enrollees, or eligible enrollees of the plan or coverage; or (B)sharing, for plan design, plan administration, and plan, financial, legal, and quality improvement activities, data described in subparagraph (A) with a business associate as defined in section 160.103 of title 45, Code of Federal Regulations (or successor regulations), consistent with the privacy regulations promulgated pursuant to section 264(c) of the Health Insurance Portability and Accountability Act, the amendments to this Act made by the Genetic Information Nondiscrimination Act of 2008, and the Americans with Disabilities Act of 1990. (3)

Clarification regarding public disclosure of information

Nothing in paragraph (1)(A) or (2)(A) prevents a health care provider, network or association of providers, or other service provider from placing reasonable restrictions on the public disclosure of the information described in such paragraphs (1) and (2). (4)

Attestation

A group health plan or a health insurance issuer offering group or individual health insurance coverage shall annually submit to, as applicable, the applicable authority described in section 2723 or the Secretary of Labor, an attestation that such plan or issuer is in compliance with the requirements of this subsection. (5)

Rule of construction

Nothing in this section shall be construed to otherwise limit group health plan, plan sponsor, or health insurance issuer access to data currently permitted under the privacy regulations promulgated pursuant to section 264(c) of the Health Insurance Portability and Accountability Act, the amendments to this Act made by the Genetic Information Nondiscrimination Act of 2008, and the Americans with Disabilities Act of 1990.

11.

Banning anticompetitive terms in facility and insurance contracts that limit access to higher quality, lower cost care

(a)

In general

Section 2729B of the Public Health Service Act, as added by section 301, is amended by adding at the end the following:

(b)

Protecting Health Plans Network Design Flexibility

(1)

In general

A group health plan or a health insurance issuer offering group or individual health insurance coverage shall not enter into an agreement with a provider, network or association of providers, or other service provider offering access to a network of service providers if such agreement, directly or indirectly— (A)restricts the group health plan or health insurance issuer from— (i)directing or steering enrollees to other health care providers; or (ii)offering incentives to encourage enrollees to utilize specific health care providers; or (B)requires the group health plan or health insurance issuer to enter into any additional contract with an affiliate of the provider, such as an affiliate of the provider, as a condition of entering into a contract with such provider; (C)requires the group health plan or health insurance issuer to agree to payment rates or other terms for any affiliate not party to the contract of the provider involved; or (D)restricts other group health plans or health insurance issuers not party to the contract from paying a lower rate for items or services than the contracting plan or issuer pays for such items or services. (2)

Additional requirement for self-insured plans

A self-insured group health plan shall not enter into an agreement with a provider, network or association of providers, third-party administrator, or other service provider offering access to a network of providers if such agreement directly or indirectly requires the group health plan to certify, attest, or otherwise confirm in writing that the group health plan is bound by restrictive contracting terms between the service provider and a third-party administrator that the group health plan is not party to, without a disclosure that such terms exist. (3)

Exception for certain group model issuers

Paragraph (1)(A) shall not apply to a group health plan or health insurance issuer offering group or individual health insurance coverage with respect to— (A)a health maintenance organization (as defined in section 2791(b)(3)), if such health maintenance organization operates primarily through exclusive contracts with multi-specialty physician groups, nor to any arrangement between such a health maintenance organization and its affiliates; or (B)a value-based network arrangement, such as an exclusive provider network, accountable care organization, center of excellence, a provider sponsored health insurance issuer that operates primarily through aligned multi-specialty physician group practices or integrated health systems, or such other similar network arrangements as determined by the Secretary through rulemaking. (4)

Attestation

A group health plan or health insurance issuer offering group or individual health insurance coverage shall annually submit to, as applicable, the applicable authority described in section 2723 or the Secretary of Labor, an attestation that such plan or issuer is in compliance with the requirements of this subsection. (c)

Maintenance of existing HIPAA, GINA, and ADA protections

Nothing in this section shall modify, reduce, or eliminate the existing privacy protections and standards provided by reason of State and Federal law, including the requirements of parts 160 and 164 of title 45, Code of Federal Regulations (or any successor regulations). (d)

Regulations

The Secretary, not later than 1 year after the date of enactment of the Hospital Competition Act of 2020, shall promulgate regulations to carry out this section. (e)

Rule of construction

Nothing in this section shall be construed to limit network design or cost or quality initiatives by a group health plan or health insurance issuer, including accountable care organizations, exclusive provider organizations, networks that tier providers by cost or quality or steer enrollees to centers of excellence, or other pay-for-performance programs. (f)

Clarification with respect to antitrust laws

Compliance with this section does not constitute compliance with the antitrust laws, as defined in subsection (a) of the first section of the Clayton Act (15 U.S.C. 12(a)).

(b)

Effective date

Section 2729B of the Public Health Service Act (as added by section 301 and amended by subsection (a)) shall apply with respect to any contract entered into on or after the date that is 18 months after the date of enactment of this Act. With respect to an applicable contract that is in effect on the date of enactment of this Act, such section 2729B shall apply on the earlier of the date of renewal of such contract or 3 years after such date of enactment.

12.

Designation of a nongovernmental, nonprofit transparency organization to lower Americans’ health care costs

(a)

In general

Subpart C of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–91 et seq.), as amended by section 102, is further amended by adding at the end the following:

2796.

Designation of a nongovernmental, nonprofit transparency organization to lower Americans’ health care costs

(a)

In general

The Secretary, in consultation with the Secretary of Labor, not later than 1 year after the date of enactment of the Hospital Competition Act of 2020, shall enter into contracts with at least 2 nonprofit entities to support the establishment and maintenance of a database that receives and utilizes health care claims information and related information and issues reports that are available to the public and authorized users, and are submitted to the Department of Health and Human Services. (b)

Requirements

(1)

In general

The database established under subsection (a) shall— (A)improve transparency by using de-identified health care data to— (i)inform patients about the cost, quality, and value of their care; (ii)assist providers and hospitals, as they work with patients, to make informed choices about care; (iii)enable providers, hospitals, and communities to improve services and outcomes for patients by benchmarking their performance against that of other providers, hospitals, and communities; (iv)enable purchasers, including employers, employee organizations, and health plans, to develop value-based purchasing models, improve quality, and reduce the cost of health care and insurance coverage for enrollees; (v)enable employers and employee organizations to evaluate network design and construction, and the cost of care for enrollees; (vi)facilitate State-led initiatives to lower health care costs and improve quality; and (vii)promote competition based on quality and cost; (B)collect medical claims, prescription drug claims, and remittance data consistent with the protections and requirements of subsection (d); (C)be established in such a manner that allows the data collected pursuant to subparagraph (B) to be shared with any State all-payer claims database or regional database operated with authorization from States, at cost, using a standardized format, if such State or regional database also submits claims data to the database established under this section; and (D)be available to— (i)the Director of the Congressional Budget Office, the Comptroller General of the United States, the Executive Director of the Medicare Payment Advisory Commission, and the Executive Director of the Medicaid and CHIP Payment Advisory Commission, upon request, subject to the privacy and security requirements of authorized users under subsection (e)(2); and (ii)authorized users, including employers, employee organizations, providers, group health plans, health insurance issuers, researchers, and policymakers, subject to subsection (e). (2)

Privacy and security; breach notifications

(A)

Regulations

(i)

In general

The Secretary shall issue regulations prescribing the extent to which, and the manner in which, the following rules (and any successors of such rules) shall apply to the activities under this section of an entity receiving a contract under subsection (a): (I)The Privacy Rule under part 160 and subparts A and E of part 164 of title 45, Code of Federal Regulations (or any successor regulations). (II)The Security Rule under part 160 and subparts A and C of part 164 of such title 45 (or any successor regulations). (III)The Breach Notification Rule under part 160 and subparts A and D of part 164 of such title 45 (or any successor regulations). (ii)

Supplemental regulations

In order to ensure data privacy and security and the notification of breaches, the Secretary may issue such supplemental regulations on the subjects of the rules listed under clause (i) as the Secretary determines appropriate to address differences between the activities described by this section and the activities covered by such rules. (B)

Enforcement

Section 1176 of Social Security Act shall apply with respect to a violation of this paragraph in the same manner such section 1176 applies to a violation of part C of title XI of the Social Security Act, and the Secretary may include in the regulations promulgated under this section provisions to apply such section to this paragraph. (C)

Procedure

(i)

Timing

The Secretary shall issue the initial set of regulations under this paragraph not later than 1 year after the date of enactment of the Hospital Competition Act of 2020. (ii)

Authority to use interim final procedures

The Secretary may make such initial set of regulations effective and final immediately upon issuance, on an interim basis, and provide for a period of public comment on such initial set of regulations after the date of publication. (D)

Requirements of entity

An entity receiving the contract under this section shall— (i)not disclose to the public any individually identifiable health information; (ii)strictly limit staff access to the data to staff with appropriate training, clearance, and background checks and require regular privacy and security training; (iii)maintain effective security standards for transferring data or making data available to authorized users; (iv)develop a process for providing access to data to authorized users, in a secure manner that maintains privacy and confidentiality of data; and (v)adhere to current best security practices with respect to the management and use of such data for health services research, in accordance with applicable Federal privacy law. (3)

Consultation

(A)

Advisory committee

Not later than 180 days after the date of enactment of the Hospital Competition Act of 2020, the Secretary shall convene an Advisory Committee (referred to in this section as the Committee), consisting of 13 members, to advise the Secretary, a contracting entity, and Congress on the establishment, operations, and use of the database established under this section. (B)

Membership

(i)

Appointment

In accordance with clause (ii), the Secretary, in consultation with the Secretary of Labor and the Comptroller General of the United States shall, not later than 180 days after the date of enactment of the Hospital Competition Act of 2020, appoint members to the Committee who have distinguished themselves in the fields of health services research, health economics, health informatics, or the governance of State all-payer claims databases, or who represent organizations likely to submit data to or use the database, including patients, employers, or employee organizations that sponsor group health plans, health care providers, health insurance issuers, or third-party administrators of group health plans. Such members shall serve 3-year terms on a staggered basis. Vacancies on the Committee shall be filled by appointment consistent with this subsection not later than 3 months after the vacancy arises. (ii)

Composition

In accordance with clause (i)— (I)the Secretary, in consultation with the Secretary of Labor, shall appoint to the Committee— (aa)1 member selected by the Secretary, in coordination with the Secretary of Labor, to serve as the chair of the Committee; (bb)the Assistant Secretary for Planning and Evaluation of the Department of Health and Human Services, or a designee of such Assistant Secretary; (cc)1 representative of the Centers for Medicare & Medicaid Services; (dd)1 representative of the Agency for Health Research and Quality; (ee)1 representative of the Office for Civil Rights of the Department of Health and Human Services with expertise in data privacy and security; (ff)1 representative of the National Center for Health Statistics; and (gg)1 representative of the Employee Benefits and Security Administration of the Department of Labor; and (II)the Comptroller General of the United States shall appoint to the Committee— (aa)1 representative of an employer that sponsors a group health plan; (bb)1 representative of an employee organization that sponsors a group health plan; (cc)1 academic researcher with expertise in health economics or health services research; (dd)1 consumer advocate; and (ee)2 additional members. (C)

Duties

The Committee shall— (i)advise the Secretary on the management of the contract under subsection (a); (ii)assist and advise the entities receiving the contract under subsection (a) in establishing— (I)the scope and format of the data to be submitted under subsection (d); (II)best practices with respect to de-identification of data, as appropriate; (III)the appropriate uses of data by authorized users, including developing standards for the approval of requests by organizations to access and use the data; and (IV)the appropriate formats and methods for making reports and analyses based on the database to the public; (iii)conduct an annual review of whether data was used according to the appropriate uses as described in clause (ii)(II), and advise the designated entities on using the data for authorized purposes; (iv)report, as appropriate, to the Secretary and Congress on the operation of the database and opportunities to better achieve the objectives of this section; (v)establish additional restrictions on researchers who receive compensation from entities described in subsection (e)(2)(B)(ii), in order to protect individually identifiable health information; and (vi)establish objectives for research and public reporting. (4)

State requirements

A State may require health insurance issuers and other payers to submit claims data to the database established under this section, provided that such data is submitted to the entities awarded contracts under this section in a form and manner established by the Secretary, and pursuant to subsection (d)(4)(B). (5)

Sanctions

The Secretary shall take appropriate action to sanction users who attempt to re-identify data accessed pursuant to paragraph (1)(D). (c)

Contract requirements

(1)

Competitive procedures

The Secretary shall enter into the contract under subsection (a) using full and open competition procedures pursuant to chapter 33 of title 41, United States Code. (2)

Eligible entities

To be eligible to enter into a contract described in subsection (a), an entity shall— (A)be a private nonprofit entity governed by a board that includes representatives of the academic research community and individuals with expertise in employer-sponsored insurance, research using health care claims data and actuarial analysis; (B)conduct its business in an open and transparent manner that provides the opportunity for public comment on its activities; and (C)agree to comply with any requirements imposed under the rulemaking described in subsection (d)(4)(A). (3)

Considerations

In awarding a contract under subsection (a), the Secretary shall consider an entity’s experience in— (A)health care claims data collection, aggregation, quality assurance, analysis, and security; (B)supporting academic research on health costs, spending, and utilization for and by privately insured patients; (C)working with large health insurance issuers and third-party administrators to assemble a national claims database; (D)effectively collaborating with and engaging stakeholders to develop reports; (E)meeting budgets and timelines, including in connection with report generation; and (F)facilitating the creation of, or supporting, State all-payer claims databases. (4)

Contract term

A contract awarded under this section shall be for a period of 5 years, and may be renewed after a subsequent competitive bidding process under this section. (5)

Transition of contract

If the Secretary, following a competitive process at the end of the contract period, selects a new entity to maintain the database, all data shall be transferred to the new entity according to a schedule and process to be determined by the Secretary. Upon termination of a contract, no entity may keep data held by the database or disclose such data to any entity other than the entity so designated by the Secretary. The Secretary shall include enforcement terms in any contract with an organization chosen under this section, to ensure the timely transfer of all data, and any associated code or algorithms, to a new entity in the event of contract termination. (d)

Receiving health information

(1)

Requirements

(A)

In general

The Secretary of Labor shall ensure that the applicable self-insured group health plan, through its third-party administrator, pharmacy benefit manager, or other entity designated by the group health plan, as applicable, electronically submits all claims data with respect to the plan, pursuant to subparagraph (B). (B)

Scope of information and format of submission

An entity awarded the contract under subsection (a), in consultation with the Committee described in subsection (b)(3), and pursuant to the privacy and security requirements of subsection (b)(2), shall— (i)specify the data elements required to be submitted under subparagraph (A), which shall include all data related to transactions described in subparagraphs (A) and (E) of section 1173(a)(2) of the Social Security Act, including all data elements normally present in such transactions when adjudicated, and enrollment information; (ii)specify the form and manner for such submissions, and the historical period to be included in the initial submission; and (iii)offer an automated submission option to minimize administrative burdens for entities required to submit data. (C)

De-identification of data

An entity awarded the contract under subsection (a) shall— (i)establish a process under which data is de-identified consistent with the de-identification requirements under section 164.514 of title 45, Code of Federal Regulations (or any successor regulations), while retaining the ability to link data longitudinally for the purposes of research on cost and quality, and the ability to complete risk adjustment and geographic analysis; (ii)ensure that any third-party subcontractors who perform the de-identification process described in clause (i) retain only the minimum necessary information to perform such a process, and adhere to effective security and encryption practices in data storage and transmission; (iii)store claims and other data collected under this subsection only in de-identified form, in accordance with section 164.514 of title 45, Code of Federal Regulations (or any successor regulations); and (iv)ensure that individually identifiable data is encrypted, in accordance with guidance issued by the Secretary under section 13402(h)(2) of the HITECH Act. (2)

Applicable self-insured group health plan

For purposes of paragraph (1), a self-insured group health plan is an applicable self-insured group health plan if such plan is self-administered, or is administered by a third-party plan administrator that meets 1 or both of the following criteria: (A)Administers health, medical, or pharmacy benefits for more than 50,000 enrollees. (B)Is one of the 5 largest administrators or issuers of self-insured group health plans in a State in which such administrator operates, as measured by the aggregate number of enrollees in plans administered by such administrator in such State, as determined by the Secretary. (3)

Third-party administrators

In the case of a third-party administrator that is required under this subsection to submit claims data with respect to an applicable self-insured group health plan, such administrator shall submit claims data with respect to all self-insured group health plans that the administrator administers, including such plans that are not applicable self-insured group health plans, as described in paragraph (2). (4)

Receiving other information

(A)

Medicare data

The Secretary, through rulemaking, shall ensure that the data made available to such entity is available to qualified entities under section 1874(e) of the Social Security Act is made available to each entity awarded a contract under subsection (a). (B)

State data

An entity awarded a contract under subsection (a) shall collect data from State all payer claims databases that seek access to the database established under this section. (5)

Availability of data

An entity required to submit data under this subsection may not place any restrictions on the use of such data by authorized users. (e)

Uses of information

(1)

In general

An entity awarded a contract under subsection (a) shall make the database available to users who are authorized under this subsection, without charge, and reports and analyses based on the data available to the public with no charge. (2)

Authorization of users

(A)

In general

An entity may request authorization by an entity awarded a contract under subsection (a) for access to the database in accordance with this paragraph. (B)

Application

An entity desiring authorization under this paragraph shall submit to an entity awarded a contract an application for such access, which shall include— (i)in the case of an entity requesting access for research purposes— (I)a description of the uses and methodologies for evaluating health system performance using such data; and (II)documentation of approval of the research by an institutional review board, if applicable for a particular plan of research; or (ii)in the case of an entity such as an employer, health insurance issuer, third-party administrator, or health care provider, requesting access for the purpose of quality improvement or cost-containment, a description of the intended uses for such data. (C)

Requirements

(i)

Research

Upon approval of an application for research purposes under subparagraph (B)(i), the authorized user shall enter into a data use and confidentiality agreement with an entity awarded a contract under subsection (a), which shall include a prohibition on attempts to reidentify and disclose individually identifiable health information. (ii)

Quality improvement and cost-containment

In consultation with the Committee described in subsection (b)(3), the Secretary shall, through rulemaking, establish the form and manner in which authorized users described in subparagraph (B)(ii) may access data. Data provided to such authorized users shall be provided in a form and manner such that users may not obtain individually identifiable price information with respect to direct competitors. Upon approval, such authorized user shall enter into a data use and confidentiality agreement with the entity. (iii)

Customized reports

Employers and employer organizations may request customized reports from an entity awarded a contract under subsection (a), at cost, subject to the requirements of this section with respect to privacy and security. (iv)

Non-customized reports

An entity awarded a contract under subsection (a), in consultation with the Committee, shall make available to all authorized users aggregate data sets, free of charge. (f)

Funding

(1)

Initial funding

There are authorized to be appropriated, and there are appropriated, out of monies in the Treasury not otherwise appropriated, $20,000,000 for fiscal year 2020, for the implementation of the initial contract and establishment of the database under this section. (2)

Ongoing funding

There are authorized to be appropriated $15,000,000 for each of fiscal years 2021 through 2025, for purposes of carrying out this section (other than the grant program under subsection (h)). (g)

Annual report

(1)

Submission

On each of the dates described in paragraph (2), an entity receiving a contract under subsection (a) shall submit to Congress, the Secretary of Health and Human Services, and the Secretary of Labor and publish online for access by the general public, a report containing a description of— (A)trends in the price, utilization, and total spending on health care services, including a geographic analysis of differences in such trends; (B)limitations in the data set; (C)progress towards the objectives of this section; and (D)the performance by the entity of the duties required under such contract. (2)

Dates described

The reports described in paragraph (1) shall be submitted— (A)not later than 3 years after the date of enactment of the Hospital Competition Act of 2020; (B)the later of 1 year after the date that is 3 years after such date of enactment or March 1 of the year after the date that is 3 years after such date of enactment; and (C)March 1 of each year thereafter. (3)

Public reports and research

An entity receiving a contract under subsection (a) shall, in coordination with authorized users, make analyses and research available to the public on an ongoing basis to promote the objectives of this section. (h)

Grants to States

(1)

In general

The Secretary, in consultation with the Secretary of Labor, may award grants to States for the purpose of establishing and maintaining State all-payer claims databases that improve transparency of data in order to meet the goals of subsection (a)(1). (2)

Requirement

To be eligible to receive the funding under paragraph (1), a State shall submit data to the database as described in subsection (b)(1)(C), using the format described in subsection (d)(1). (3)

Funding

There is authorized to be appropriated $100,000,000 for the period of fiscal years 2020 through 2029 for the purpose of awarding grants to States under this subsection. (i)

Exemption from public disclosure

(1)

In general

Claims data provided to the database, and the database itself shall not be considered public records and shall be exempt from public disclosure requirements. (2)

Restrictions on uses for certain proceedings

Data disclosed to authorized users shall not be subject to discovery or admission as public information, or evidence in judicial or administrative proceedings without consent of the affected parties. (j)

Individually identifiable health information defined

The term individually identifiable health information has the meaning given such term in section 1171(6) of the Social Security Act. (k)

Rule of construction

Nothing in this section shall be construed to affect or modify enforcement of the privacy, security, or breach notification rules promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (or successor regulations).

(b)

GAO report

(1)

In general

The Comptroller General of the United States shall conduct a study on— (A)the performance of the entity awarded a contract under section 2795(a) of the Public Health Service Act, as added by subsection (a), under such contract; (B)the privacy and security of the information reported to the entity; and (C)the costs incurred by such entity in performing such duties. (2)

Reports

Not later than 2 years after the effective date of the first contract entered into under section 2795(a) of the Public Health Service Act, as added by subsection (a), and again not later than 4 years after such effective date, the Comptroller General of the United States shall submit to Congress a report containing the results of the study conducted under paragraph (1), together with recommendations for such legislation and administrative action as the Comptroller General determines appropriate.

13.

Protecting patients and improving the accuracy of provider directory information

(a)

In general

Subpart II of part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–11 et seq.), as amended by sections 301 and 302, is further amended by adding at the end the following:

2729C.

Protecting patients and improving the accuracy of provider directory information

(a)

Network status of providers

(1)

In general

Beginning on the date that is one year after the date of enactment of this section, a group health plan or a health insurance issuer offering group or individual health insurance coverage shall— (A)establish business processes to ensure that all enrollees in such plan or coverage receive proof of a health care provider’s network status, based on what a plan or issuer knows or could reasonably know— (i)through a written electronic communication from the plan or issuer to the enrollee, as soon as practicable and not later than 1 business day after a telephone inquiry is made by such enrollee for such information; (ii)through an oral confirmation, documented by such issuer or coverage, and kept in the enrollee’s file for a minimum of 2 years; and (iii)in real-time through an online health care provider directory search tool maintained by the plan or issuer; and (B)include in any print directory a disclosure that the information included in the directory is accurate as of the date of the last data update and that enrollees or prospective enrollees should consult the group health plan or issuer’s electronic provider directory on its website or call a specified customer service telephone number to obtain the most current provider directory information. (2)

Group health plan and health insurance issuer business processes

Beginning on the date that is one year after the date of enactment of the Hospital Competition Act of 2020, a group health plan or a health insurance issuer offering group or individual health insurance coverage shall establish business processes to— (A)verify and update, at least once every 90 days, the provider directory information for all providers included in the online health care provider directory search tool described in paragraph (1)(A)(iii); and (B)remove any provider from such online directory search tool if such provider has not verified the directory information within the previous 6 months or the plan or issuer has been unable to verify the provider's network participation. (b)

Cost-Sharing limitations

(1)

In general

A group health plan or a health insurance issuer offering group or individual health insurance coverage shall not apply, and shall ensure that no provider applies cost-sharing to an enrollee for treatment or services provided by a health care provider in excess of the normal cost-sharing applied for in-network care (including any balance bill issued by the health care provider involved), if such enrollee, or health care provider referring such enrollee, demonstrates (based on the electronic, written information described in subsection (a)(1)(A)(i), the oral confirmation described in subsection (a)(1)(A)(ii), or a copy of the online provider directory described in subsection (a)(1)(A)(iii) on the date the enrollee attempted to obtain the provider’s network status) that the enrollee relied on the information described in subsection (a)(1), if the provider’s network status or directory information on such directory was incorrect at the time the treatment or services involved was provided. (2)

Refunds to enrollees

If a health care provider submits a bill to an enrollee in violation of paragraph (1), and the enrollee pays such bill, the provider shall reimburse the enrollee for the full amount paid by the enrollee in excess of the in-network cost-sharing amount for the treatment or services involved, plus interest, at an interest rate determined by the Secretary. (c)

Provider business processes

A health care provider shall have in place business processes to ensure the timely provision of provider directory information to a group health plan or a health insurance issuer offering group or individual health insurance coverage to support compliance by such plans or issuers with subsection (a)(1). Such providers shall submit provider directory information to a plan or issuers, at a minimum— (1)when the provider begins a network agreement with a plan or with an issuer with respect to certain coverage; (2)when the provider terminates a network agreement with a plan or with an issuer with respect to certain coverage; (3)when there are material changes to the content of provider directory information described in subsection (a)(1); and (4)every 90 days throughout the duration of the network agreement with a plan or issuer. (d)

Enforcement

(1)

In general

Subject to paragraph (2), a health care provider that violates a requirement under subsection (c) or takes actions that prevent a group health plan or health insurance issuer from complying with subsection (a)(1) or (b) shall be subject to a civil monetary penalty of not more than $10,000 for each act constituting such violation. (2)

Safe harbor

The Secretary may waive the penalty described under paragraph (1) with respect to a health care provider that unknowingly violates subsection (b)(1) with respect to an enrollee if such provider rescinds the bill involved and, if applicable, reimburses the enrollee within 30 days of the date on which the provider billed the enrollee in violation of such subsection. (3)

Procedure

The provisions of section 1128A of the Social Security Act, other than subsections (a) and (b) and the first sentence of subsection (c)(1) of such section, shall apply to civil money penalties under this subsection in the same manner as such provisions apply to a penalty or proceeding under section 1128A of the Social Security Act. (e)

Savings clause

Nothing in this section shall prohibit a provider from requiring in the terms of a contract, or contract termination, with a group health plan or health insurance issuer— (1)that the plan or issuer remove, at the time of termination of such contract, the provider from a directory of the plan or issuer described in subsection (a)(1); or (2)that the plan or issuer bear financial responsibility, including under subsection (b), for providing inaccurate network status information to an enrollee. (f)

Definition

For purposes of this section, the term provider directory information includes the names, addresses, specialty, and telephone numbers of individual health care providers, and the names, addresses, and telephone numbers of each medical group, clinic, or facility contracted to participate in any of the networks of the group health plan or health insurance coverage involved. (g)

Rule of construction

Nothing in this section shall be construed to preempt any provision of State law relating to health care provider directories or network adequacy.

(b)

Effective date

Section 2729C of the Public Health Service Act, as added by subsection (a), shall take effect with respect to plan years beginning on or after the date that is 18 months after the date of enactment of this Act.

14.

Timely bills for patients

(a)

In general

(1)

Amendment

Part P of title III of the Public Health Service Act (42 U.S.C. 280g et seq.) is amended by adding at the end the following:

399V–7.

Timely bills for patients

(a)

In general

The Secretary shall require— (1)health care facilities, or in the case of practitioners providing services outside of such a facility, practitioners, to provide to patients a list of services rendered during the visit to such facility or practitioner, and, in the case of a facility, the name of the provider for each such service, upon discharge or end of the visit or by postal or electronic communication as soon as practicable and not later than 5 calendar days after discharge or date of visit; and (2)health care facilities and practitioners to furnish all adjudicated bills to the patient as soon as practicable, but not later than 45 calendar days after discharge or date of visit. (b)

Payment after billing

No patient may be required to pay a bill for health care services any earlier than 35 days after the postmark date of a bill for such services. (c)

Effect of violation

(1)

Notification and refund requirements

(A)

Provider lists

If a facility or practitioner fails to provide a patient a list as required under subsection (a)(1), such facility or practitioner shall report such failure to the Secretary. (B)

Billing

If a facility or practitioner bills a patient after the 45-calendar-day period described in subsection (a)(2), such facility or practitioner shall— (i)report such bill to the Secretary; and (ii)refund the patient for the full amount paid in response to such bill with interest, at a rate determined by the Secretary. (2)

Civil monetary penalties

(A)

In general

The Secretary may impose civil monetary penalties of up to $10,000 a day on any facility or practitioner that— (i)fails to provide a list required under subsection (a)(1) more than 10 times, beginning on the date of such tenth failure; (ii)submits more than 10 bills outside of the period described in subsection (a)(2), beginning on the date on which such facility or practitioner sends the tenth such bill; (iii)fails to report to the Secretary any failure to provide lists as required under paragraph (1)(A), beginning on the date that is 45 calendar days after discharge or visit; or (iv)fails to send any bill as required under subsection (a)(2), beginning on the date that is 45 calendar days after the date of discharge or visit, as applicable. (B)

Procedure

Safe harbor

The Secretary may exempt a practitioner or facility from the penalties under paragraph (2)(A) or extend the period of time specified under subsection (a)(2) for compliance with such subsection if a practitioner or facility— (A)makes a good-faith attempt to send a bill within 30 days but is unable to do so because of an incorrect address; or (B)experiences extenuating circumstances (as defined by the Secretary), such as a hurricane or cyberattack, that may reasonably delay delivery of a timely bill.

(2)

Rulemaking

Not later than 1 year after the date of enactment of this Act, the Secretary shall promulgate final regulations to define the term extenuating circumstance for purposes of section 399V–7(c)(3)(B) of the Public Health Service Act, as added by paragraph (1). (b)

Group health plan and health insurance issuer requirements

Subpart II of part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–11), as amended by section 304, is further amended by adding at the end the following:

2729D.

Timely bills for patients

(a)

In general

A group health plan or health insurance issuer offering group or individual health insurance coverage shall have in place business practices with respect to in-network facilities and practitioners to ensure that claims are adjudicated in order to facilitate facility and practitioner compliance with the requirements under section 399V–7(a). (b)

Clarification

Nothing in subsection (a) prohibits a provider and a group health plan or health insurance issuer from establishing in a contract the timeline for submission by either party to the other party of billing information, adjudication, sending of remittance information, or any other coordination required between the provider and the plan or issuer necessary for meeting the deadline described in section 399V–7(a)(2).

(c)

Effective date

The amendments made by subsections (a) and (b) shall take effect 6 months after the date of enactment of this Act.

15.

Government Accountability Office study on profit- and revenue-sharing in health care

(a)

Study

Not later than 1 year after the date of enactment of this Act, the Comptroller General of the United States shall conduct a study to— (1)describe what is known about profit- and revenue-sharing relationships in the commercial health care markets, including those relationships that— (A)involve one or more— (i)physician groups that practice within a hospital included in the profit- or revenue-sharing relationship, or refer patients to such hospital; (ii)laboratory, radiology, or pharmacy services that are delivered to privately insured patients of such hospital; (iii)surgical services; (iv)hospitals or group purchasing organizations; or (v)rehabilitation or physical therapy facilities or services; and (B)include revenue- or profit-sharing whether through a joint venture, management or professional services agreement, or other form of gain-sharing contract; (2)describe Federal oversight of such relationships, including authorities of the Department of Health and Human Services and the Federal Trade Commission to review such relationships and their potential to increase costs for patients, and identify limitations in such oversight; and (3)as appropriate, make recommendations to improve Federal oversight of such relationships. (b)

Report

Not later than 1 year after the date of enactment of this Act, the Comptroller General of the United States shall prepare and submit a report on the study conducted under subsection (a) to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Education and Labor and Committee on Energy and Commerce of the House of Representatives.

16.

Ensuring enrollee access to cost-sharing information

(a)

In general

Subpart II of part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–11 et seq.), as amended by section 306, is further amended by adding at the end the following:

2729F.

Provision of cost-sharing information

(a)

Provider disclosures

A provider that is in-network with respect to a group health plan or a health insurance issuer offering group or individual health insurance coverage shall provide to an enrollee in the plan or coverage who submits a request for the information described in paragraph (1) or (2), together with accurate and complete information about the enrollee’s coverage under the applicable plan or coverage— (1)as soon as practicable and not later than 2 business days after the enrollee requests such information, a good faith estimate of the expected enrollee cost-sharing for the provision of a particular health care service (including any service that is reasonably expected to be provided in conjunction with such specific service); and (2)as soon as practicable and not later than 2 business days after an enrollee requests such information, the contact information for any ancillary providers for a scheduled health care service. (b)

Insurer disclosures

A group health plan or a health insurance issuer offering group or individual health insurance coverage shall provide an enrollee in the plan or coverage with a good faith estimate of the enrollee's cost-sharing (including deductibles, copayments, and coinsurance) for which the enrollee would be responsible for paying with respect to a specific health care service (including any service that is reasonably expected to be provided in conjunction with such specific service), as soon as practicable and not later than 2 business days after a request for such information by an enrollee. (c)

Enforcement

(1)

In general

Subject to paragraph (2), a health care provider that violates a requirement under subsection (a) shall be subject to a civil monetary penalty of not more than $10,000 for each act constituting such violation. (2)

Procedure

(b)

Effective date

Section 2729G of the Public Health Service Act, as added by subsection (a), shall apply with respect to plan years beginning on or after the date that is 18 months after the date of enactment of this Act.

17.

Group health plan reporting requirements

Part C of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–91 et seq.), as amended by section 303, is further amended by adding at the end the following:

2797.

Group health plan reporting

(a)

In general

A group health plan or health insurance issuer offering group or individual health insurance coverage shall submit to the Secretary, not later than March 1 of each year, the following information with respect to the health plan in the previous plan year: (1)The beginning and end dates of the plan year. (2)The number of enrollees. (3)Each State in which the plan is offered. (4)The 50 brand prescription drugs most frequently dispensed by pharmacies for claims paid by the issuer, and the total number of paid claims for each such drug. (5)The 50 most costly prescription drugs with respect to the plan by total annual spending, and the annual amount spent by the plan for each such drug. (6)The 50 prescription drugs with the greatest increase in plan expenditures over the plan year preceding the plan year that is the subject of the report, and, for each such drug, the change in amounts expended by the plan in each such plan year. (7)Total spending on health care services by such group health plan, broken down by— (A)the type of costs, including— (i)hospital costs; (ii)health care provider and clinical service costs; (iii)costs for prescription drugs; and (iv)other medical costs; and (B)spending on prescription drugs by— (i)the health plan; and (ii)the enrollees. (8)The average monthly premium— (A)paid by employers on behalf of enrollees; and (B)paid by enrollees. (9)Any impact on premiums by rebates, fees, and any other remuneration paid by drug manufacturers to the plan or its administrators or service providers, with respect to prescription drugs prescribed to enrollees in the plan, including— (A)the amounts so paid for each therapeutic class of drugs; and (B)the amounts so paid for each of the 25 drugs that yielded the highest amount of rebates and other remuneration under the plan from drug manufacturers during the plan year. (10)Any reduction in premiums and out-of-pocket costs associated with rebates, fees, or other remuneration described in paragraph (9). (b)

Report

Not later than 18 months after the date on which the first report is required under subsection (a) and biannually thereafter, the Secretary, acting through the Assistant Secretary of Planning and Evaluation and in coordination with the Inspector General of the Department of Health and Human Services, shall make available on the internet website of the Department of Health and Human Services a report on prescription drug reimbursements under group health plans, prescription drug pricing trends, and the role of prescription drug costs in contributing to premium increases or decreases under such plans, aggregated in such a way as no drug or plan specific information will be made public. (c)

Privacy protections

No confidential or trade secret information submitted to the Secretary under subsection (a) shall be included in the report under subsection (b).