Health Care Price Check Act of 2019

II 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 pro- gram, and for other purposes. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE. 3 This Act may be cited as the ‘‘Health Care Price 4 Check Act of 2019’’. 5 SEC. 2. IMPROVING COST AND QUALITY TRANSPARENCY 6 UNDER THE MEDICARE PROGRAM. 7 (a) SECRETARY.— 8 (1) IN GENERAL.—Section 1804 of the Social 9 Security Act (42 U.S.C. 1395b–2) is amended— 10 VerDate Sep 11 2014 16:54 May 25, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\S1497.IS S1497 pamtmann on DSKBFK8HB2PROD with BILLS 2 •S 1497 IS (A) in subsection (b), in the first sentence, 1 by striking ‘‘The Secretary’’ and inserting 2 ‘‘Subject to subsection (e)(1), the Secretary’’; 3 and 4 (B) by adding at the end the following new 5 subsection: 6 ‘‘(e) COST AND QUALITY TRANSPARENCY.— 7 ‘‘(1) REQUIREMENTS FOR TOLL-FREE TELE- 8 PHONE NUMBER.—Not later than 1 year after the 9 date of the enactment of this Act (except as pro- 10 vided in subparagraph (A)(iv)), the Secretary shall 11 ensure that the following information is available to 12 an individual who calls the toll-free telephone num- 13 ber under subsection (b): 14 ‘‘(A) COSTS.—The following information 15 regarding costs for items and services under 16 parts A and B: 17 ‘‘(i) The individual’s out-of-pocket 18 costs for a specific item or service fur- 19 nished by a specific provider of services or 20 supplier. 21 ‘‘(ii) The payment amount under this 22 title for such item or service furnished by 23 such provider or supplier. 24 VerDate Sep 11 2014 16:54 May 25, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S1497.IS S1497 pamtmann on DSKBFK8HB2PROD with BILLS 3 •S 1497 IS ‘‘(iii) The total allowable charges for 1 such item or service furnished by such pro- 2 vider or supplier. 3 ‘‘(iv) Not later than 2 years after the 4 date of the enactment of this Act, the in- 5 formation described in clauses (i) through 6 (iii) for items and services that are fre- 7 quently furnished together with the item or 8 service described in such clauses, as deter- 9 mined by the Secretary. 10 ‘‘(v) An explanation of the cost-shar- 11 ing components under parts A and B, in- 12 cluding with respect to— 13 ‘‘(I) deductibles; 14 ‘‘(II) copayments; and 15 ‘‘(III) coinsurance. 16 ‘‘(B) QUALITY.—Quality information avail- 17 able through the Medicare Physician Compare, 18 Hospital Compare, Nursing Home Compare, 19 Dialysis Facility Compare, Inpatient Rehabilita- 20 tion Facility Compare, Long-Term Care Hos- 21 pital Compare, and Hospice Compare websites. 22 ‘‘(C) ADDITIONAL INFORMATION.—Other 23 cost and quality information determined appro- 24 priate by the Secretary. 25 VerDate Sep 11 2014 16:54 May 25, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S1497.IS S1497 pamtmann on DSKBFK8HB2PROD with BILLS 4 •S 1497 IS ‘‘(2) INTERNET WEBSITE.— 1 ‘‘(A) IN GENERAL.—Not later than 2 years 2 after the date of the enactment of this Act, the 3 Secretary shall ensure that an internet website 4 is in place that meets the following require- 5 ments: 6 ‘‘(i) SEARCH FUNCTION.—Subject to 7 clause (iv), the internet website contains a 8 search function that enables an individual 9 to search for an item or service in a geo- 10 graphic area— 11 ‘‘(I) by the type of item or serv- 12 ice; and 13 ‘‘(II) by providers of services or 14 suppliers, including both a general 15 search and search by a specific name. 16 ‘‘(ii) INFORMATION.—The internet 17 website is able to provide the information 18 described in paragraph (1). 19 ‘‘(iii) COMPARE FUNCTION.—The 20 internet website contains a compare func- 21 tion that enables an individual to compare 22 the out-of-pocket costs and quality for an 23 item or service furnished by different pro- 24 viders of services or suppliers. 25 VerDate Sep 11 2014 16:54 May 25, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S1497.IS S1497 pamtmann on DSKBFK8HB2PROD with BILLS 5 •S 1497 IS ‘‘(B) LIMIT.—The Secretary may limit the 1 number of items and services for which infor- 2 mation is available on the website but shall en- 3 sure that items and services which account for 4 at least 50 percent of spending under parts A 5 and B are included. 6 ‘‘(C) EXISTING WEBSITE.—The Secretary 7 may comply with the requirements under this 8 paragraph through the use of an internet 9 website that is in place as of the date of the en- 10 actment of this subsection. 11 ‘‘(3) ALERT REGARDING ESTIMATES OF 12 COSTS.—The Secretary shall ensure that individuals 13 receiving cost information under paragraph (1) or 14 (2) are alerted that the information provided is an 15 estimate and that the actual costs that the indi- 16 vidual will be responsible for may vary.’’. 17 (2) FUNDING.—There are appropriated to the 18 Secretary of Health and Human Services such sums 19 as the Secretary determines are necessary to carry 20 out subsection (e) of section 1804 of the Social Se- 21 curity Act, as added by paragraph (1). 22 (b) MEDICARE ADVANTAGE.—Section 1852 of the 23 Social Security Act (42 U.S.C. 1395w–22) is amended— 24 VerDate Sep 11 2014 16:54 May 25, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S1497.IS S1497 pamtmann on DSKBFK8HB2PROD with BILLS 6 •S 1497 IS (1) in subsection (c), by adding at the end the 1 following new paragraph: 2 ‘‘(3) COST AND QUALITY TRANSPARENCY.—For 3 plan year 2021 and subsequent plan years, subject 4 to paragraph (4) of subsection (o), the Medicare Ad- 5 vantage organization shall comply with the require- 6 ments under such subsection).’’; and 7 (2) by adding at the end the following new sub- 8 section: 9 ‘‘(o) COST AND QUALITY TRANSPARENCY.— 10 ‘‘(1) TOLL-FREE TELEPHONE NUMBER.— 11 ‘‘(A) IN GENERAL.—Each Medicare Ad- 12 vantage organization offering a Medicare Ad- 13 vantage plan shall have in place a toll-free tele- 14 phone number under which enrollees in the plan 15 that call the telephone number are able to re- 16 ceive the following information: 17 ‘‘(i) COSTS FOR ITEMS AND SERV- 18 ICES.—The following information regard- 19 ing costs for items and services under the 20 plan: 21 ‘‘(I) The enrollee’s out-of-pocket 22 costs for a specific item or service fur- 23 nished by a specific in-network pro- 24 vider of services or supplier. 25 VerDate Sep 11 2014 16:54 May 25, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S1497.IS S1497 pamtmann on DSKBFK8HB2PROD with BILLS 7 •S 1497 IS ‘‘(II) The information described 1 in subclause (I) for items and services 2 that are frequently furnished together 3 with the item or service described in 4 such subclause, as determined by the 5 Secretary. 6 ‘‘(III) An explanation of the cost- 7 sharing components, both generally 8 and under the plan specifically, in- 9 cluding with respect to— 10 ‘‘(aa) deductibles; 11 ‘‘(bb) copayments; and 12 ‘‘(cc) coinsurance. 13 ‘‘(ii) COSTS FOR COVERED PART D 14 DRUGS.—In the case of an MA–PD plan, 15 the information described in section 16 1860D–4(o)(1)(A). 17 ‘‘(iii) QUALITY.—Information on the 18 quality of items and services furnished by 19 providers of services and suppliers under 20 the plan, as determined appropriate by the 21 Secretary. 22 ‘‘(iv) OUT-OF-NETWORK PRO- 23 VIDERS.—If an enrollee of the plan re- 24 VerDate Sep 11 2014 16:54 May 25, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S1497.IS S1497 pamtmann on DSKBFK8HB2PROD with BILLS 8 •S 1497 IS quests information on an out-of-network 1 provider of services or supplier,— 2 ‘‘(I) information on the out-of- 3 network benefits offered under the 4 plan; and 5 ‘‘(II) other information, as deter- 6 mined appropriate by the Secretary. 7 ‘‘(v) ADDITIONAL INFORMATION.— 8 Other cost and quality information deter- 9 mined appropriate by the Secretary. 10 ‘‘(B) ACCESS.—The toll-free telephone 11 number under subparagraph (A) shall be acces- 12 sible by calling a number directly or by charge- 13 free transfer pursuant to section 1804(b). 14 ‘‘(C) INTEGRATION WITH EXISTING TELE- 15 PHONE NUMBER.—The requirements for a toll- 16 free telephone number under subparagraph (A) 17 may be provided through an existing enrollee 18 toll-free telephone number. 19 ‘‘(2) INTERNET WEBSITE.— 20 ‘‘(A) IN GENERAL.—Subject to clause (iv), 21 each Medicare Advantage organization offering 22 a Medicare Advantage plan shall have in place 23 an internet website that meets the following re- 24 quirements: 25 VerDate Sep 11 2014 16:54 May 25, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S1497.IS S1497 pamtmann on DSKBFK8HB2PROD with BILLS 9 •S 1497 IS ‘‘(i) SEARCH FUNCTION.—The inter- 1 net website contains a search function that 2 enables an enrollee to search— 3 ‘‘(I) for an item or service in a 4 geographic area— 5 ‘‘(aa) by the type of item or 6 service; and 7 ‘‘(bb) by providers of serv- 8 ices or suppliers; and 9 ‘‘(II) in the case of an MA–PD 10 plan, for a covered part D drug under 11 the plan. 12 ‘‘(ii) INFORMATION.—The internet 13 website is able to provide the information 14 described in— 15 ‘‘(I) paragraph (1)(A); and 16 ‘‘(II) in the case of an MA–PD 17 plan, section 1860D–4(o)(1)(A). 18 ‘‘(iii) COMPARE FUNCTION.—The 19 internet website contains a compare func- 20 tion that enables an enrollee to compare— 21 ‘‘(I) the out-of-pocket costs and 22 quality for an item or service fur- 23 nished by different providers of serv- 24 ices or suppliers; and 25 VerDate Sep 11 2014 16:54 May 25, 2019 Jkt 089200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S1497.IS S1497 pamtmann on DSKBFK8HB2PROD with BILLS 10 •S 1497 IS ‘‘(II) in the case of an MA–PD 1 plan, each of subclauses (I) and (II) 2 of section 1860D–4(o)(2)(A)(iii) for a 3 covered part D drug. 4 ‘‘(iv) LIMIT.—A Medicare Advantage 5 organization may limit the number of 6 items and services for which information is 7 available on the website pursuant to the 8 limits established by the Secretary under 9 section 1804(e)(2)(A)(iv). 10 ‘‘(B) INTEGRATION WITH EXISTING INTER- 11 NET WEBSITE.—If a Medicare Advantage orga- 12 nization offering a Medicare Advantage plan 13 has in place an internet website for the plan as 14 of the date of the enactment of this subsection, 15 the organization shall integrate the require- 16 ments under subparagraph (A) into such 17 website, including through the same log-in proc- 18 ess as the existing website. 19 ‘‘(C) LINK TO AN EXTERNAL INTERNET 20 WEBSITE FOR INFORMATION ON COVERED PART 21 D DRUGS.—A Medicare Advantage organization 22 offering a Medicare Advantage plan may pro- 23 vide the information described subparagraph 24 (A)(ii)(II) for the plan through a link on the 25 VerDate Sep 11 2014 16:54 May 25, 2019 Jkt 089200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S1497.IS S1497 pamtmann on DSKBFK8HB2PROD with BILLS 11 •S 1497 IS plan’s internet website to an external internet 1 website. 2 ‘‘(3) ALERT REGARDING ESTIMATES OF 3 COSTS.—Each Medicare Advantage organization of- 4 fering a Medicare Advantage plan shall ensure that 5 enrollees of the plan receiving cost information 6 under paragraph (1) or (2) are alerted that the in- 7 formation provided is an estimate and that the ac- 8 tual costs that the enrollee will be responsible for 9 may vary. 10 ‘‘(4) EXEMPTION.—The requirements of this 11 subsection shall not apply to a Medicare Advantage 12 organization if the total number of enrollees in all 13 the Medicare Advantage plans offered by the organi- 14 zation is less than a number of enrollees determined 15 appropriate by the Secretary.’’. 16 (c) PRESCRIPTION DRUG PLANS.—Section 1860D–4 17 of the Social Security Act (42 U.S.C. 1395w–104) is 18 amended— 19 (1) by redesignating the subsection (m) as 20 added by section 6063(c) of the SUPPORT for Pa- 21 tients and Communities Act (Public Law 115–271) 22 as subsection (n); and 23 (2) by adding at the end the following new sub- 24 section: 25 VerDate Sep 11 2014 16:54 May 25, 2019 Jkt 089200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S1497.IS S1497 pamtmann on DSKBFK8HB2PROD with BILLS 12 •S 1497 IS ‘‘(o) COST TRANSPARENCY.—For plan year 2021 and 1 subsequent plan years, subject to paragraph (4), each 2 PDP sponsor offering a prescription drug plan shall com- 3 ply with the following: 4 ‘‘(1) TOLL-FREE TELEPHONE NUMBER.— 5 ‘‘(A) IN GENERAL.—The PDP sponsor of- 6 fering the prescription drug plan shall have in 7 place a toll-free telephone number under which 8 enrollees in the plan that call the telephone 9 number are able to receive the following infor- 10 mation: 11 ‘‘(i) The enrollee’s out-of-pocket costs 12 for a specific covered part D drug filled by 13 a specific in-network pharmacy. 14 ‘‘(ii) An explanation of the cost-shar- 15 ing components for covered part D drugs, 16 both generally and under the plan specifi- 17 cally, including with respect to— 18 ‘‘(I) deductibles; 19 ‘‘(II) copayments; and 20 ‘‘(III) coinsurance. 21 ‘‘(B) INTEGRATION WITH EXISTING TELE- 22 PHONE NUMBER.—The requirements for a toll- 23 free telephone number under subparagraph (A) 24 VerDate Sep 11 2014 16:54 May 25, 2019 Jkt 089200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\S1497.IS S1497 pamtmann on DSKBFK8HB2PROD with BILLS 13 •S 1497 IS may be provided through an existing enrollee 1 toll-free telephone number. 2 ‘‘(2) INTERNET WEBSITE.— 3 ‘‘(A) IN GENERAL.—Each PDP sponsor 4 offering a prescription drug plan shall have in 5 place an internet website that meets the fol- 6 lowing requirements: 7 ‘‘(i) SEARCH FUNCTION.—The inter- 8 net website contains a search function that 9 enables an enrollee to search for a covered 10 part D drug under the plan. 11 ‘‘(ii) INFORMATION.—The internet 12 website is able to provide the information 13 described in subparagraph (A) of para- 14 graph (1). 15 ‘‘(iii) COMPARE FUNCTION.—The 16 internet website contains a compare func- 17 tion that enables an enrollee to compare 18 each of the following for a covered part D 19 drug: 20 ‘‘(I) The out-of-pocket costs for 21 multiple pharmacies, including mail 22 order if available. 23 ‘‘(II) The out-of-pocket costs for 24 clinically equivalent therapeutic op- 25 VerDate Sep 11 2014 16:54 May 25, 2019 Jkt 089200 PO 00000 Frm 00013 Fmt 6652 Sfmt 6201 E:\BILLS\S1497.IS S1497 pamtmann [Text truncated for display. 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