Promoting Transparency and Healthy Competition in Medicare Act

I 118TH CONGRESS 1ST SESSION H. R. 3282 To amend title XVIII of the Social Security Act to promote transparency of common ownership interests under parts C and D of the Medicare program. IN THE HOUSE OF REPRESENTATIVES MAY 15, 2023 Mrs. HARSHBARGER (for herself, Ms. SCHRIER, Mr. BILIRAKIS, and Ms. SCHAKOWSKY) introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on En- ergy 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 promote transparency of common ownership interests under parts C and D of the Medicare program. 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 ‘‘Promoting Trans- 4 parency and Healthy Competition in Medicare Act’’. 5 VerDate Sep 11 2014 00:51 May 27, 2023 Jkt 039200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H3282.IH H3282 kjohnson on DSK79L0C42PROD with BILLS 2 •HR 3282 IH SEC. 2. PROMOTING TRANSPARENCY OF COMMON OWNER- 1 SHIP INTERESTS UNDER PARTS C AND D OF 2 THE MEDICARE PROGRAM. 3 (a) MEDICARE ADVANTAGE.—Section 1857(e) of the 4 Social Security Act (42 U.S.C. 1395w–27(e)) is amended 5 by adding at the end the following new paragraph: 6 ‘‘(6) REQUIRED DISCLOSURE OF CERTAIN IN- 7 FORMATION RELATING TO HEALTH CARE PROVIDER 8 OWNERSHIP.— 9 ‘‘(A) IN GENERAL.—For plan years begin- 10 ning on or after January 1, 2025, a contract 11 under this section with an MA organization 12 shall require the organization to report to the 13 Secretary, not later than 1 year after the last 14 day of such plan year, the information de- 15 scribed in subparagraph (B) with respect to 16 such plan year. 17 ‘‘(B) INFORMATION DESCRIBED.—For pur- 18 poses of subparagraph (A), the information de- 19 scribed in this subparagraph is, with respect to 20 an MA organization and a plan year, the fol- 21 lowing: 22 ‘‘(i) The number of items and services 23 furnished during such plan year by each 24 specified provider (as defined in subpara- 25 VerDate Sep 11 2014 00:51 May 27, 2023 Jkt 039200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H3282.IH H3282 kjohnson on DSK79L0C42PROD with BILLS 3 •HR 3282 IH graph (C)) for which payment was made 1 by such organization. 2 ‘‘(ii) The number of items and serv- 3 ices furnished during such plan year by 4 providers of services or suppliers not de- 5 scribed in clause (i) for which payment was 6 made by such organization. 7 ‘‘(iii) The average per-enrollee number 8 of qualifying diagnoses (as defined in sub- 9 paragraph (C)) made during such plan 10 year by specified providers (including 11 through chart reviews and health risk as- 12 sessments) with respect to individuals en- 13 rolled under an MA plan offered by such 14 organization, broken down by site of serv- 15 ice of such providers, as specified by the 16 Secretary. 17 ‘‘(iv) The average per-enrollee number 18 of qualifying diagnoses made during such 19 plan year by providers of services and sup- 20 pliers not described in clause (iii) (includ- 21 ing through such reviews and assessments) 22 with respect to such individuals, broken 23 down by site of service of such providers. 24 VerDate Sep 11 2014 00:51 May 27, 2023 Jkt 039200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H3282.IH H3282 kjohnson on DSK79L0C42PROD with BILLS 4 •HR 3282 IH ‘‘(v) The average risk score (as cal- 1 culated under the methodology described in 2 subparagraph (C)(i)) for such an indi- 3 vidual for such plan year who received 4 items and services from a specified pro- 5 vider during such plan year. 6 ‘‘(vi) The average risk score for such 7 an individual for such plan year who did 8 not receive items and services from a speci- 9 fied provider during such plan year. 10 ‘‘(vii) The average risk score for such 11 an individual for such plan year who re- 12 ceived a health risk assessment from an 13 assessment entity that was a specified as- 14 sessment entity during such plan year. 15 ‘‘(viii) The average risk score for such 16 an individual for such plan year who re- 17 ceived a health risk assessment from an 18 assessment entity that was not a specified 19 assessment entity during such plan year. 20 ‘‘(ix) The number of prior authoriza- 21 tion requests for an item or service sub- 22 mitted to such organization during such 23 plan year, the number of such requests 24 that were approved, the number of such re- 25 VerDate Sep 11 2014 00:51 May 27, 2023 Jkt 039200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H3282.IH H3282 kjohnson on DSK79L0C42PROD with BILLS 5 •HR 3282 IH quests that were denied, and the number 1 of such denied requests that were subse- 2 quently appealed and then approved, bro- 3 ken down by whether the entity proposing 4 to furnish such item or service was a speci- 5 fied provider or not a specified provider. 6 ‘‘(x) The total amount of incentive- 7 based payments made to, and the total 8 amount of shared losses recoupments col- 9 lected from, specified providers during 10 such plan year. 11 ‘‘(xi) The total amount of incentive- 12 based payments made to, and the total 13 amount of shared losses recoupments col- 14 lected from, providers of services and sup- 15 pliers not described in clause (x) during 16 such plan year. 17 ‘‘(xii) For each MA plan offered by 18 such organization during such plan year— 19 ‘‘(I) the total amount of pay- 20 ments made under section 1853(a)(1) 21 to such organization for coverage of 22 individuals under such plan, and the 23 total amount of payments made by 24 VerDate Sep 11 2014 00:51 May 27, 2023 Jkt 039200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H3282.IH H3282 kjohnson on DSK79L0C42PROD with BILLS 6 •HR 3282 IH such individuals to such organization 1 for coverage under such plan; 2 ‘‘(II) the total amount expended 3 under such plan as payment for items 4 and services furnished by each speci- 5 fied provider during such year; 6 ‘‘(III) the total amount expended 7 under such plan as payment for items 8 and services furnished by providers of 9 services or suppliers not described in 10 subclause (II) during such year; 11 ‘‘(IV) the medical loss ratio 12 under such plan with respect to indi- 13 viduals furnished an item or service 14 from a specified provider during such 15 year; and 16 ‘‘(V) the medical loss ratio under 17 such plan with respect to individuals 18 not described in subclause (IV). 19 ‘‘(C) DEFINITIONS.—In this paragraph: 20 ‘‘(i) ASSESSMENT ENTITY.—The term 21 ‘assessment entity’ means an entity with a 22 focus on furnishing in-home medical as- 23 sessments, as specified by the Secretary. 24 VerDate Sep 11 2014 00:51 May 27, 2023 Jkt 039200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H3282.IH H3282 kjohnson on DSK79L0C42PROD with BILLS 7 •HR 3282 IH ‘‘(ii) QUALIFYING DIAGNOSIS.—The 1 term ‘qualifying diagnosis’ means, with re- 2 spect to an individual, a diagnosis that is 3 taken into account in calculating a risk 4 score for such individual under the risk ad- 5 justment methodology established by the 6 Secretary pursuant to section 1853(a)(3). 7 ‘‘(iii) SPECIFIED ASSESSMENT ENTI- 8 TY.—The term ‘specified assessment enti- 9 ty’ means, with respect to an MA organiza- 10 tion and a plan year, an assessment entity 11 with respect to which such organization (or 12 any person with an ownership or control 13 interest (as defined in section 1124(a)(3)) 14 in such organization) is a person with an 15 ownership or control interest (as so de- 16 fined). 17 ‘‘(iv) SPECIFIED PROVIDER.—The 18 term ‘specified provider’ means, with re- 19 spect to an MA organization and a plan 20 year, a provider of services or supplier with 21 respect to which such organization (or any 22 person with an ownership or control inter- 23 est (as defined in section 1124(a)(3)) in 24 such organization) is a person with an 25 VerDate Sep 11 2014 00:51 May 27, 2023 Jkt 039200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H3282.IH H3282 kjohnson on DSK79L0C42PROD with BILLS 8 •HR 3282 IH ownership or control interest (as so de- 1 fined). 2 ‘‘(D) NONAPPLICATION OF PAPERWORK 3 REDUCTION ACT.—Chapter 35 of title 44, 4 United States Code, shall not apply to informa- 5 tion collected under this paragraph.’’. 6 (b) PHARMACY BENEFIT MANAGER AND PHARMACY 7 INFORMATION.—Section 1860D–12(b) of the Social Secu- 8 rity Act (42 U.S.C. 1395w–112(b)) is amended by adding 9 at the end the following new paragraphs: 10 ‘‘(9) PROVISION OF INFORMATION RELATING TO 11 PHARMACY OWNERSHIP.— 12 ‘‘(A) IN GENERAL.—For plan years begin- 13 ning on or after January 1, 2025, a contract 14 entered into under this part with a PDP spon- 15 sor shall require the sponsor to report to the 16 Secretary, not later than 1 year after the last 17 day of such plan year, the information de- 18 scribed in subparagraph (B) with respect to 19 such plan year. 20 ‘‘(B) INFORMATION DESCRIBED.—For pur- 21 poses of subparagraph (A), the information de- 22 scribed in this subparagraph is, for each pre- 23 scription drug plan offered by a PDP sponsor 24 for a plan year, the following: 25 VerDate Sep 11 2014 00:51 May 27, 2023 Jkt 039200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H3282.IH H3282 kjohnson on DSK79L0C42PROD with BILLS 9 •HR 3282 IH ‘‘(i) The negotiated price for each cov- 1 ered part D drug for which benefits are 2 available under such plan for each network 3 pharmacy (including an identification of 4 whether each such pharmacy is a specified 5 pharmacy). 6 ‘‘(ii) The average per-drug amount of 7 direct and indirect remuneration paid by 8 specified pharmacies for such covered part 9 D drugs dispensed during such plan year 10 under such plan. 11 ‘‘(iii) The average per-drug amount of 12 direct and indirect remuneration paid by 13 pharmacies not described in clause (ii) for 14 such covered part D drugs dispensed dur- 15 ing such plan year under such plan. 16 ‘‘(C) DEFINITIONS.—In this paragraph: 17 ‘‘(i) DIRECT AND INDIRECT REMU- 18 NERATION.—The term ‘direct and indirect 19 remuneration’ has the meaning given such 20 term in section 423.308 of title 42, Code 21 of Federal Regulations (or any successor 22 regulation). 23 ‘‘(ii) NETWORK PHARMACY.—The 24 term ‘network pharmacy’ has the meaning 25 VerDate Sep 11 2014 00:51 May 27, 2023 Jkt 039200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H3282.IH H3282 kjohnson on DSK79L0C42PROD with BILLS 10 •HR 3282 IH given such term in section 423.100 of title 1 42, Code of Federal Regulations (or any 2 successor regulation). 3 ‘‘(iii) NEGOTIATED PRICE.—The ‘ne- 4 gotiated price’ for a covered part D drug 5 shall take into account all negotiated price 6 concessions, such as discounts, direct or in- 7 direct subsidies, rebates, and direct or indi- 8 rect remunerations, for such drug, and in- 9 clude any dispensing fee for such drug. 10 ‘‘(iv) SPECIFIED PHARMACY.—The 11 term ‘specified pharmacy’ means, with re- 12 spect to an PDP sponsor and a plan year, 13 a pharmacy with respect to which such 14 sponsor (or any person with an ownership 15 or control interest (as defined in section 16 1124(a)(3)) in such sponsor) is a person 17 with an ownership or control interest (as 18 so defined). 19 ‘‘(D) NONAPPLICATION OF PAPERWORK 20 REDUCTION ACT.—Chapter 35 of title 44, 21 United States Code, shall not apply to informa- 22 tion collected under this paragraph. 23 ‘‘(10) PROVISION OF INFORMATION BY PHAR- 24 MACY BENEFIT MANAGERS.— 25 VerDate Sep 11 2014 00:51 May 27, 2023 Jkt 039200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H3282.IH H3282 kjohnson on DSK79L0C42PROD with BILLS 11 •HR 3282 IH ‘‘(A) IN GENERAL.—For plan years begin- 1 ning on or after January 1, 2025, a contract 2 entered into under this part with a PDP spon- 3 sor shall prohibit such sponsor from entering 4 into a contract with a specified pharmacy ben- 5 efit manager for purposes of performing any 6 service with respect to covered part D drugs 7 dispensed under any prescription drug plan of- 8 fered by such sponsor for such plan year unless 9 such manager agrees to report to the Secretary, 10 not later than 1 year after the last day of such 11 plan year, the information described in subpara- 12 graph (B) with respect to each prescription 13 drug plan for which such manager is providing 14 any such service during such plan year, regard- 15 less of the sponsor of such plan. 16 ‘‘(B) INFORMATION DESCRIBED.—For pur- 17 poses of subparagraph (A), the information de- 18 scribed in this subparagraph is, with respect to 19 a pharmacy benefit manager performing serv- 20 ices under a prescription drug plan for a plan 21 year, the following: 22 ‘‘(i) With respect to the total amount 23 of pharmacy and manufacturer rebates col- 24 lected by such manager (or collected on be- 25 VerDate Sep 11 2014 00:51 May 27, 2023 Jkt 039200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H3282.IH H3282 kjohnson on DSK79L0C42PROD with BILLS 12 •HR 3282 IH half of such plan by any other entity with 1 a contract in effect with such manager for 2 such collection) for all covered part D 3 drugs dispensed under such plan during 4 such plan year— 5 ‘‘(I) the total amount of such re- 6 bates passed through to the PDP 7 sponsor of such plan; and 8 ‘‘(II) the total amount of such re- 9 bates retained by such manager or 10 such other entities. 11 ‘‘(ii) The total amount paid by such 12 manager to pharmacies for drugs furnished 13 under such plan during such plan year. 14 ‘‘(iii) The total amount of payments 15 made by such sponsor to such manager as 16 reimbursement for such manager’s pay- 17 ments described in clause (ii). 18 ‘‘(iv) The total amount of payments 19 made by such sponsor to such manager as 20 fees for services furnished by such man- 21 ager with respect to such plan for such 22 plan year (not including payments de- 23 scribed in clause (iii)). 24 VerDate Sep 11 2014 00:51 May 27, 2023 Jkt 039200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\H3282.IH H3282 kjohnson on DSK79L0C42PROD with BILLS 13 •HR 3282 IH ‘‘(v) The total amount of administra- 1 tive costs incurred by such manager for 2 furnishing such services under such plan 3 for such plan year. 4 ‘‘(vi) A specification as to whether 5 such manager is a specified pharmacy ben- 6 efit manager with respect to the PDP 7 sponsor of such plan. 8 ‘‘(C) DEFINITION.—In this paragraph, the 9 term ‘specified pharmacy benefit manager’ 10 means, with respect to an PDP sponsor and a 11 plan year, a pharmacy benefit manager with re- 12 spect to which such sponsor (or any person with 13 an ownership or control intere [Text truncated for display. 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