Requiring disclosure of percentage of in-network participation for certain provider types

(a)

PHSA

Part D of title XXVII of the Public Health Service Act (42 U.S.C. 300g–111 et seq.) is amended by adding at the end the following new section:

2799A–11.

Required disclosure of percentage of in-network participation for certain provider types

(a)

In general

A group health plan and a health insurance issuer offering group or individual health insurance coverage shall, along with any summary of benefits and coverage provided under section 2715 (and in accordance with the timing and manner specified under such section and the implementing regulations of such section), and on the public website of such plan or issuer, make available the following information with respect to each type of provider specified in subsection (b):(1)The number and percentage of providers of such type located in the service area of such plan or coverage that have a contractual relationship (as defined by the Secretary) in effect with such plan or coverage for furnishing items and services under such plan or coverage, determined in accordance with information made available by the Secretary under subsection (d).(2)The designation established by the Secretary under subsection (c) corresponding to the percentage described in paragraph (1).(b)

Specified providers

For purposes of this section, the types of providers and facilities specified in this subsection are the following (as defined by the Secretary and broken down by subspecialty as specified by the Secretary):(1)Behavioral health care providers and facilities.(2)Substance use disorder treatment providers and facilities.(c)

Establishment of designations of in-Network participation

(1)

In general

Not later than 1 year after the date of the enactment of this section, the Secretary, in consultation with the Secretaries of Labor and of the Treasury, shall establish a system of designations (such as high, medium, and low, a star rating, or such other designation determined appropriate by the Secretary) that correspond to ranges of percentages (from 0 to 100) described in subsection (a)(1) to qualitatively reflect the breadth of the networks of group health plans and group and individual health insurance coverage with respect to each type of provider specified in subsection (b).(2)

Variation permitted

Designations corresponding to percentage ranges established under paragraph (1) may vary by type of service area (such as rural or urban), size of service area, and other factors determined appropriate by the Secretary in consultation with the Secretaries of Labor and of the Treasury.(d)

Information on providers

(1)

In general

Not later than June 30, 2026, the Secretary, in consultation with the Secretaries of Labor and of the Treasury, shall, based on information submitted under section 2799B–10, post on the public website of the Department of Health and Human Services, a list of each specified provider in the country, including—(A)the location of each such provider in which such provider furnishes items and services;(B)each specialty designation (if any) of each such provider;(C)whether such provider treats individuals under the age of 19; and(D)whether such provider accepts telehealth appointments. The Secretary shall update the information published under the previous sentence not less frequently than annually.

The Secretary shall update the information published under this paragraph not less frequently than annually.

(2)

Treatment of group practices

For purposes of the list described in paragraph (1), the Secretary shall list each individual health care provider separately, regardless of whether such provider is part of a group practice. (e)

Service area definition

For purposes of this section, the term service area means, with respect to a group health plan and group or individual health insurance coverage, the area or areas in which in-person participants and beneficiaries are covered, as determined by the plan or issuer of such coverage in accordance with rules specified by the Secretary in consultation with the Secretaries of Labor and of the Treasury.

(b)

ERISA

(1)

In general

Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 is amended by adding at the end the following new section:

726.

Required disclosure of percentage of in-network participation for certain provider types

(a)

In general

A group health plan and a health insurance issuer offering group health insurance coverage shall, along with any summary of benefits and coverage provided under section 2715 of the Public Health Service Act (and in accordance with the timing and manner specified under such section and the implementing regulations of such section), and on the public website of such plan or issuer, make available the following information with respect to each type of provider specified in subsection (b):(1)The number and percentage of providers of such type located in the service area of such plan or coverage that have a contractual relationship (as defined by the Secretary) in effect with such plan or coverage for furnishing items and services under such plan or coverage, determined in accordance with information made available by the Secretary under subsection (d).(2)The designation established by the Secretary under subsection (c) corresponding to the percentage described in paragraph (1).(b)

Specified providers

Establishment of designations of in-Network participation

(1)

In general

Not later than 1 year after the date of the enactment of this section, the Secretary, in consultation with the Secretaries of Health and Human Services and of the Treasury, shall establish a system of designations (such as high, medium, and low, a star rating, or such other designation determined appropriate by the Secretary) that correspond to ranges of percentages (from 0 to 100) described in subsection (a)(1) to qualitatively reflect the breadth of the networks of group health plans and group health insurance coverage with respect to each type of provider specified in subsection (b).(2)

Variation permitted

Information on providers

(1)

In general

Not later than June 30, 2026, the Secretary, in consultation with the Secretaries of Health and Human Services and of the Treasury, shall, based on information submitted under section 2799B–10, post on the public website of the Department of Labor, a list of each specified provider in the country, including—(A)the location of each such provider in which such provider furnishes items and services;(B)each specialty designation (if any) of each such provider;(C)whether such provider treats individuals under the age of 19; and(D)whether such provider accepts telehealth appointments. The Secretary shall update the information published under the previous sentence not less frequently than annually.

The Secretary shall update the information published under this paragraph not less frequently than annually.

(2)

Treatment of group practices

For purposes of the list described in paragraph (1), the Secretary shall list each individual health care provider separately, regardless of whether such provider is part of a group practice. (e)

Service area definition

For purposes of this section, the term service area means, with respect to a group health plan and group health insurance coverage, the area or areas in which in-person participants and beneficiaries are covered, as determined by the plan or issuer of such coverage in accordance with rules specified by the Secretary in consultation with the Secretaries of Health and Human Services and of the Treasury.

(2)

Technical amendment

The table of contents in section 1 of such Act is amended by inserting after the item relating to section 725 the following new item:

Sec. 726. Required disclosure of percentage of in-network participation for certain provider types.

(c)

IRC

(1)

In general

Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following new section:

9826.

Required disclosure of percentage of in-network participation for certain provider types

(a)

In general

A group health plan shall, along with any summary of benefits and coverage provided under section 2715 of the Public Health Service Act (and in accordance with the timing and manner specified under such section and the implementing regulations of such section), and on the public website of such plan, make available the following information with respect to each type of provider specified in subsection (b):(1)The number and percentage of providers of such type located in the service area of such plan that have a contractual relationship (as defined by the Secretary) in effect with such plan for furnishing items and services under such plan, determined in accordance with information made available by the Secretary under subsection (d).(2)The designation established by the Secretary under subsection (c) corresponding to the percentage described in paragraph (1).(b)

Specified providers

Establishment of designations of in-Network participation

(1)

In general

Not later than 1 year after the date of the enactment of this section, the Secretary, in consultation with the Secretaries of Health and Human Services and of Labor, shall establish a system of designations (such as high, medium, and low, a star rating, or such other designation determined appropriate by the Secretary) that correspond to ranges of percentages (from 0 to 100) described in subsection (a)(1) to qualitatively reflect the breadth of the networks of group health plans with respect to each type of provider specified in subsection (b).(2)

Variation permitted

Information on providers

(1)

In general

Not later than June 30, 2026, the Secretary, in consultation with the Secretaries of Health and Human Services and of Labor, shall, based on information submitted under section 2799B–10, post on the public website of the Department of the Treasury, a list of each specified provider in the country, including—(A)the location of each such provider in which such provider furnishes items and services;(B)each specialty designation (if any) of each such provider;(C)whether such provider treats individuals under the age of 19; and(D)whether such provider accepts telehealth appointments. The Secretary shall update the information published under the previous sentence not less frequently than annually.

The Secretary shall update the information published under this paragraph not less frequently than annually.

(2)

Treatment of group practices

For purposes of the list described in paragraph (1), the Secretary shall list each individual health care provider separately, regardless of whether such provider is part of a group practice. (e)

Service area definition

For purposes of this section, the term service area means, with respect to a group health plan, the area or areas in which in-person participants and beneficiaries are covered, as determined by the plan in accordance with rules specified by the Secretary in consultation with the Secretaries of Health and Human Services and of Labor.

(2)

Technical amendment

The table of sections for such subchapter is amended by adding at the end the following new item:

Sec. 9826. Required disclosure of percentage of in-network participation for certain provider types.

(d)

Provider requirements

Part E of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–131 et seq.) is amended by adding at the end the following new section:

2799B–10.

Provision of certain information to the Secretary

(a)

In general

Subject to subsection (b), in the case of a health care provider or health care facility that is a specified provider (as described in subsection (b) of section 2799A–11), such provider or facility shall, annually at a time and in a manner specified by the Secretary, provide to the Secretary such information as the Secretary determines necessary to carry out subsection (d) of such section. (b)

Exception

Subsection (a) shall not apply in the case of a specified provider that has not, during the 1-year period ending on the date that information described in subsection (a) would be required to be submitted to the Secretary by such provider without application of this subsection, submitted any claim for an item or service under a Federal health care program (as defined in section 1128B of the Social Security Act), the program established under chapter 89 of title 5, United States Code, or a group health plan or group or individual health insurance coverage.

(e)

Report

Not later than December 31, 2027, and annually thereafter, the Secretary of Health and Human Services shall submit to Congress a report on the participation of behavioral health care and substance use disorder treatment providers in networks established by group health plan and health insurance issuers offering group or individual health insurance coverage (as such terms are defined in section 2791 of the Public Health Service Act (42 U.S.C. 300gg–91)). Each such report shall include data and analysis relating to service areas (as defined in section 2799A–11 of such Act) of such plans and issuers that the Secretary has identified as having low participation rates with respect to such providers’ participation in such networks. (f)

Implementation

The Secretaries of Labor, Health and Human Services, and the Treasury may implement the amendments made by this section through interim final rule, subregulatory guidance, program instruction, or otherwise.(g)

Funding

In addition to amounts otherwise available for such purposes, there is appropriated $15,000,000, to remain available until expended, for purposes of carrying out this section.(h)

Effective date

The amendments made by this section shall apply with respect to plan years beginning on or after January 1, 2027.