[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4883 Introduced in House (IH)]

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118th CONGRESS
  1st Session
                                H. R. 4883

    To amend title XVIII of the Social Security Act to require the 
  disclosure of certain ownership information relating to health care 
        provider and pharmacy ownership, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             July 25, 2023

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

_______________________________________________________________________

                                 A BILL


 
    To amend title XVIII of the Social Security Act to require the 
  disclosure of certain ownership information relating to health care 
        provider and pharmacy ownership, 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 ``Medicare Common Ownership 
Transparency Act of 2023''.

SEC. 2. REPORT ON INTEGRATION IN MEDICARE.

    (a) Required MA and PDP Reporting.--
            (1) MA plans.--Section 1857(e) of the Social Security Act 
        (42 U.S.C. 1395w-27(e)) is amended by adding at the end the 
        following new paragraph:
            ``(6) Required disclosure of certain information relating 
        to health care provider ownership.--
                    ``(A) In general.--For plan year 2025 and for every 
                third plan year thereafter, each MA organization 
                offering an MA plan under this part during such plan 
                year shall submit to the Secretary, at a time and in a 
                manner specified by the Secretary--
                            ``(i) the taxpayer identification number 
                        for each health care provider that was a 
                        specified health care provider with respect to 
                        such organization during such year;
                            ``(ii) the total amount of incentive-based 
                        payments made to, and the total amount of 
                        shared losses recoupments collected from, such 
                        specified health care providers during such 
                        plan year; and
                            ``(iii) the total amount of incentive-based 
                        payments made to, and the total amount of 
                        shared losses recoupments collected from, 
                        providers of services and suppliers not 
                        described in clause (ii) during such plan year.
                    ``(B) Definition.--For purposes of this paragraph, 
                the term `specified health care provider' means, with 
                respect to an MA organization and a plan year, a 
                provider of services or supplier with respect to which 
                such organization (or any person with an ownership or 
                control interest (as defined in section 1124(a)(3)) in 
                such organization) is a person with an ownership or 
                control interest (as so defined).''.
            (2) Prescription drug plans.--Section 1860D-12(b) of the 
        Social Security Act (42 U.S.C. 1395w-112(b)) is amended by 
        adding at the end the following new paragraph:
            ``(9) Provision of information relating to pharmacy 
        ownership.--
                    ``(A) In general.--For plan year 2025 and for every 
                third plan year thereafter, each PDP sponsor offering a 
                prescription drug plan under this part during such plan 
                year shall submit to the Secretary, at a time and in a 
                manner specified by the Secretary, the taxpayer 
                identification number and National Provider Identifier 
                for each pharmacy that was a specified pharmacy with 
                respect to such sponsor during such year.
                    ``(B) Definition.--For purposes of this paragraph, 
                the term `specified pharmacy' means, with respect to an 
                PDP sponsor offering a prescription drug plan and a 
                plan year, a pharmacy with respect to which--
                            ``(i) such sponsor (or any person with an 
                        ownership or control interest (as defined in 
                        section 1124(a)(3)) in such sponsor) is a 
                        person with an ownership or control interest 
                        (as so defined); or
                            ``(ii) a pharmacy benefit manager offering 
                        services under such plan (or any person with an 
                        ownership or control interest (as so defined) 
                        in such sponsor) is a person with an ownership 
                        or control interest (as so defined).''.
    (b) MedPAC Reports.--Part E of title XVIII of the Social Security 
Act (42 U.S.C. 1395x et seq.) is amended by adding at the end the 
following new section:

``SEC. 1899C. REPORTS ON VERTICAL INTEGRATION UNDER MEDICARE.

    ``(a) In General.--Not later than June 15, 2029, and every 3 years 
thereafter, the Medicare Payment Advisory Commission shall submit to 
Congress a report on the state of vertical integration in the health 
care sector during the applicable year with respect to entities 
participating in the Medicare program, including health care providers, 
pharmacies, prescription drug plan sponsors, Medicare Advantage 
organizations, and pharmacy benefit managers. Such report shall 
include--
            ``(1) with respect to Medicare Advantage organizations, the 
        evaluation described in subsection (b);
            ``(2) with respect to prescription drug plans, pharmacy 
        benefit managers, and pharmacies, the comparisons and 
        evaluations described in subsection (c);
            ``(3) with respect to Medicare Advantage plans under which 
        benefits are available for physician-administered drugs, the 
        information described in subsection (d); and
            ``(4) the identifications described in subsection (e); and
            ``(5) an analysis of the impact of such integration on 
        health care access, price, quality, and outcomes.
    ``(b) Medicare Advantage Organizations.--For purposes of subsection 
(a)(1), the evaluation described in this subsection is, with respect to 
Medicare Advantage organizations and an applicable year, an evaluation, 
taking into account patient acuity and the types of areas serviced by 
such organization, of--
            ``(1) the average number of qualifying diagnoses made 
        during such year with respect to enrollees of a Medicare 
        Advantage plan offered by such organization who, during such 
        year, received a health risk assessment from a specified health 
        care provider;
            ``(2) the average risk score for such enrollees who 
        received such an assessment during such year;
            ``(3) any relationship between such risk scores for such 
        enrollees receiving such an assessment from such a provider 
        during such year and incentive payments made to such providers;
            ``(4) the average risk score for enrollees of such plan who 
        received any item or service from a specified health care 
        provider during such year;
            ``(5) any relationship between the risk scores of enrollees 
        under such plan and whether the enrollees have received any 
        item or service from a specified provider; and
            ``(6) any relationship between the risk scores of enrollees 
        under such plan that have received any item or service from a 
        specified provider and incentive payments made under the plan 
        to specified providers.
    ``(c) Prescription Drug Plans.--For purposes of subsection (a)(2), 
the comparisons and evaluations described in this subsection are, with 
respect to prescription drug plans and an applicable year, the 
following:
            ``(1) For each covered part D drug for which benefits are 
        available under such a plan, a comparison of the average 
        negotiated rate in effect with specified pharmacies with such 
        rates in effect for in-network pharmacies that are not 
        specified pharmacies.
            ``(2) Comparisons of the following:
                    ``(A) The total amount paid by pharmacy benefit 
                managers to specified pharmacies for covered part D 
                drugs and the total amount so paid to pharmacies that 
                are not specified pharmacies for such drugs.
                    ``(B) The total amount paid by such sponsors to 
                specified pharmacy benefit managers as reimbursement 
                for covered part D drugs and the total amount so paid 
                to pharmacy benefit managers that are not specified 
                pharmacy benefit managers as such reimbursement.
                    ``(C) Fees paid under by plan to specified pharmacy 
                benefit managers compared to such fees paid to pharmacy 
                benefit managers that are not specified pharmacy 
                benefit managers.
            ``(3) An evaluation of the total amount of direct and 
        indirect remuneration for covered part D drugs passed through 
        to prescription drug plan sponsors and the total amount 
        retained by pharmacy benefit managers (including entities under 
        contract with such a manager).
            ``(4) To the extent that the available data permits, an 
        evaluation of fees charged by rebate aggregators that are 
        affiliated with plan sponsors.
    ``(d) Physician-Administered Drugs.--For purposes of subsection 
(a)(3), the information described in this subsection is, with respect 
to physician-administered drugs for which benefits are available under 
a Medicare Advantage plan during an applicable year, the following:
            ``(1) With respect to each such plan, an identification of 
        each drug for which benefits were available under such plan 
        only when administered by a health care provider that acquired 
        such drug from an affiliated pharmacy.
            ``(2) An evaluation of the difference between the total 
        number of drugs administered by a health care provider that 
        were acquired from affiliated pharmacies compared to the number 
        of such drugs so administered that were acquired from 
        pharmacies other than affiliated pharmacies, and an evaluation 
        of the difference in payments for such drugs so administered 
        when acquired from a specified pharmacy and when acquired from 
        a pharmacy that is not a specified pharmacy.
            ``(3) An evaluation of the dollar value of all such drugs 
        that were not so administered because of a delay attributable 
        to an affiliated pharmacy compared to the dollar value of all 
        such drugs that were not so administered because of a delay 
        attributable to pharmacy that is not an affiliated pharmacy.
            ``(4) The number of enrollees administered such a drug that 
        was acquired from an affiliated pharmacy.
            ``(5) The number of enrollees furnished such a drug that 
        was acquired from a pharmacy that is not an affiliated 
        pharmacy.
    ``(e) Identifications.--For purposes of subsection (a)(4), the 
identifications described in this subsection are, with respect to an 
applicable year, identifications of each health care entity 
participating under the Medicare program with respect to which another 
health care entity so participating is a person with an ownership or 
control interest (as defined in section 1124(a)(3) of the Social 
Security Act (42 U.S.C. 1320a-3(a)(3))).
    ``(f) Definitions.--In this section:
            ``(1) Affiliated pharmacy.--The term `affiliated pharmacy' 
        means, with respect to a Medicare Advantage plan offered by a 
        Medicare Advantage organization, a pharmacy with respect to 
        which such organization (or any person with an ownership or 
        control interest (as defined in section 1124(a)(3)) in such 
        organization) is a person with an ownership or control interest 
        (as so defined).
            ``(2) Applicable year.--The term `applicable year' means, 
        with respect to a report submitted under subsection (a), the 
        first calendar year beginning at least 4 years prior to the 
        date of the submission of such report.
            ``(3) Covered part d drug.--The term `covered part D drug' 
        has the meaning given such term in section 1860D-2(e).
            ``(4) Direct and indirect remuneration.--The term `direct 
        and indirect remuneration' has the meaning given such term in 
        section 423.308 of title 42, Code of Federal Regulations (or 
        any successor regulation).
            ``(5) Qualifying diagnosis.--The term `qualifying 
        diagnosis' means, with respect to an enrollee of a Medicare 
        Advantage plan, a diagnosis that is taken into account in 
        calculating a risk score for such enrollee under the risk 
        adjustment methodology established by the Secretary pursuant to 
        section 1853(a)(3).
            ``(6) Risk score.--The term `risk score' means, with 
        respect to an enrollee of a Medicare Advantage plan, the score 
        calculated for such individual using the methodology described 
        in paragraph (5).
            ``(7) Physician-administered drug.--The term `physician-
        administered drug' means a drug furnished to an individual 
        that, had such individual been enrolled under part B and not 
        enrolled under part C, would have been payable under section 
        1842(o).
            ``(8) Specified health care provider.--The term `specified 
        health care provider' means, with respect to a Medicare 
        Advantage plan offered by a Medicare Advantage organization, a 
        health care provider with respect to which such organization 
        (or any person with an ownership or control interest (as 
        defined in section 1124(a)(3)) in such organization) is a 
        person with an ownership or control interest (as so defined).
            ``(9) Specified pharmacy.--The term `specified pharmacy' 
        means, with respect to a prescription drug plan offered by a 
        prescription drug plan sponsor, a pharmacy with respect to 
        which--
                    ``(A) such sponsor (or any person with an ownership 
                or control interest (as defined in section 1124(a)(3)) 
                in such sponsor) is a person with an ownership or 
                control interest (as so defined); or
                    ``(B) a pharmacy benefit manager offering services 
                under such plan (or any person with an ownership or 
                control interest (as so defined) in such sponsor) is a 
                person with an ownership or control interest (as so 
                defined).
            ``(10) Specified pharmacy benefit manager.--The term 
        `specified pharmacy benefit manager' means, with respect to a 
        prescription drug plan offered by a prescription drug plan 
        sponsor, a pharmacy benefit manager with respect to which such 
        sponsor (or any person with an ownership or control interest 
        (as defined in section 1124(a)(3)) in such sponsor) is a person 
        with an ownership or control interest (as so defined).''.
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