Sec. 501. Requirement to provide health claims, network, and cost information
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Part A of title XXVII of the Public Health Service Act ( 42 U.S.C. 300gg et seq.) is amended by inserting after section 2715A the following: A group health plan or a health insurance issuer offering group or individual health insurance coverage shall make available for access, exchange, or use without special effort, through application programming interfaces (or successor technology or standards), the information described in subsection (b), in the manner described in subsection
(b)and otherwise consistent with this section. The following information is required to be made available, in such form and manner as the Secretary may specify, as described in subsection (a): Historical claims, provider encounter, and payment data for each enrollee, which shall— include adjudicated medical and prescription drug claims and equivalent encounters, including all data elements contained in such transactions— that were adjudicated by the group health plan or health insurance issuer during the previous 5 years or the enrollee’s entire period of enrollment in the applicable plan or coverage if such period is less than 5 years; that involve benefits managed by any third party, such as a pharmacy benefits manager or radiology benefits manager that manages benefits or adjudicates claims on behalf of the plan or coverage; and from any other health plan or health insurance coverage issued or administered by the same insurance issuer, in which the same enrollee was enrolled during the previous 5 years; and be available— in a single, longitudinal format that is easy to understand and secure, and that may update automatically, including by using the standards adopted for implementation of section 3001(c)(5)(D)(iv); as soon as practicable, and in no case later than the period of time determined by the Secretary, after the claim is adjudicated or the data is received by the health plan or health insurance issuer; and to the enrollee, and any providers or third-party applications or services authorized by the enrollee, for 5 years after the end date of the enrollee’s enrollment in the plan or in any coverage offered by the health insurance issuer. Identifying directory information for all in-network providers, including facilities and practitioners, that participate in the plan or coverage, which shall— include— the national provider identifier for in-network facilities and practitioners; and the name, address, phone number, and specialty for each such facility and practitioner, based on the most recent interaction between the plan or coverage and that facility or practitioner; be capable of returning a list of participating in-network facilities and practitioners, in a given specialty or at a particular facility type, within a specified geographic radius; and be capable of returning the network status, when presented with identifiers for a given enrollee and facility or practitioner. Estimated patient out-of-pocket costs, including costs expected to be incurred through a deductible, copayment, coinsurance, or other form of cost-sharing, for— a designated set of common services or episodes of care, to be established by the Secretary through rulemaking, including, at a minimum— in the case of services provided by a hospital, the 100 most common diagnosis-related groups, as used in the Medicare Inpatient Prospective Patient System (or successor episode-based reimbursement methodology) at that hospital, based on claims data adjudicated by the group health plan or health insurance issuer; in the case of services provided in an outpatient setting, including radiology, lab tests, and outpatient surgical procedures, any service rendered by the facility or practitioner, and reimbursed by the health plan or health insurance issuer; and in the case of post-acute care, including home health providers, skilled nursing facilities, inpatient rehabilitation facilities, and long-term care hospitals, the patient out-of-pocket costs for an episode of care, as the Secretary may determine, which permits users to reasonably compare costs across different facility and service types; and all prescription drugs currently included on any tier of the formulary of the plan or coverage. The application programming interfaces, including all data required to be made available through such interfaces, shall— be made available by the applicable group health plan or health insurance issuer, at no charge, to— enrollees in the group health plan or health insurance coverage; third parties authorized by the enrollee; facilities and practitioners who are under contract with the plan or coverage; and business associates of such facilities and practitioners, as defined in section 160.103 of title 45, Code of Federal Regulations (or any successor regulations); be available to enrollees in the group health plan or health insurance coverage, and to third-party applications or services facilitating such access by enrollees, during the enrollment process and for a minimum of 5 years after the end date of the enrollee’s enrollment in the plan or in any coverage offered by the health insurance issuer; permit persistent access by third-party applications or services authorized by the enrollee, for a reasonable period of time, consistent with current security practices; employ the applicable content, vocabulary, and technical standards, including, as appropriate, such standards adopted by the Secretary pursuant to title XXX; and employ security and authentication standards, as the Secretary determines appropriate. Nothing in this section shall be construed to alter existing obligations under the privacy, security, and breach notification rules promulgated under section 264(c) of the Health Insurance Portability and Accountability Act (or successor regulations), under part 2 of title 42, Code of Federal Regulations (or successor regulations), under section 444 of the General Education Provisions Act ( 20 U.S.C. 1232g ) (commonly referred to as the Family Educational Rights and Privacy Act of 1974 ), under the amendments made by the Genetic Information Nondiscrimination Act, or under State privacy law. . Section 2715B of the Public Health Service Act, as added by subsection (a), shall take effect 1 year after the date of enactment of this Act.
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Sec. 501
Requirement to provide health claims, network, and cost information
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