[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[S. 1497 Introduced in Senate (IS)]

<DOC>






116th CONGRESS
  1st Session
                                S. 1497

  To amend title XVIII of the Social Security Act to improve cost and 
    quality transparency under the Medicare program, and for other 
                               purposes.


_______________________________________________________________________


                   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.

    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 ``Health Care Price Check Act of 
2019''.

SEC. 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.''.

SEC. 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:

``SEC. 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.
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