Sec. 301. Banning anticompetitive terms in facility and insurance contracts that limit access to higher quality, lower cost care
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/bill/118/s/2840/rs/section-301A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Section 2799A–9 of the Public Health Service Act ( 42 U.S.C. 300gg–119 ) is amended— by adding at the end the following: A group health plan or a health insurance issuer offering group or individual health insurance coverage shall not enter into an agreement with a provider, network or association of providers, or other service provider offering access to a network of service providers if such agreement, directly or indirectly— restricts the group health plan or health insurance issuer from— directing or steering enrollees to other health care providers; or offering incentives to encourage enrollees to utilize specific health care providers; requires the group health plan or health insurance issuer to enter into any additional contract with an affiliate of the provider as a condition of entering into a contract with such provider; requires the group health plan or health insurance issuer to agree to payment rates or other terms for any affiliate not party to the contract of the provider involved; or restricts other group health plans or health insurance issuers not party to the contract from paying a lower rate for items or services than the contracting plan or issuer pays for such items or services.
A self-insured group health plan shall not enter into an agreement with a provider, network or association of providers, third-party administrator, or other service provider offering access to a network of providers if such agreement directly or indirectly requires the group health plan to certify, attest, or otherwise confirm in writing that the group health plan is bound by restrictive contracting terms between the service provider and a third-party administrator that the group health plan is not party to, without a disclosure that such terms exist.
Paragraph (1)(A) shall not apply to a group health plan or health insurance issuer offering group or individual health insurance coverage with respect to— a health maintenance organization (as defined in section 2791(b)(3)), if such health maintenance organization operates primarily through exclusive contracts with multi-specialty physician groups, nor to any arrangement between such a health maintenance organization and its affiliates; or a value-based network arrangement, such as an exclusive provider network, accountable care organization, center of excellence, a provider sponsored health insurance issuer that operates primarily through aligned multi-specialty physician group practices or integrated health systems, or such other similar network arrangements as determined by the Secretary through rulemaking.
A group health plan or health insurance issuer offering group or individual health insurance coverage shall annually submit to, as applicable, the applicable authority described in section 2723 or the Secretary of Labor or the Secretary of the Treasury, an attestation that such plan or issuer is in compliance with the requirements of this subsection. Nothing in this subsection shall be construed to limit network design or cost or quality initiatives by a group health plan or health insurance issuer, including accountable care organizations, exclusive provider organizations, networks that tier providers by cost or quality or steer enrollees to centers of excellence, or other pay-for-performance programs.
Compliance with this subsection does not constitute compliance with the antitrust laws, as defined in subsection
(a)of the first section of the Clayton Act ( 15 U.S.C. 12(a) ). An applicable State authority may make a determination that the prohibitions under paragraph
(1)(with respect to conditions that would direct or steer to, or offer incentives to encourage enrollees to use, other health care providers) will not apply in the State with respect to any specified agreement that is executed before the date of enactment of the Bipartisan Primary Care and Health Workforce Act , for a maximum length of nonapplicability of up to 10 years from the date of execution of the contract if the applicable State authority determines that the contract is unlikely to significantly lessen competition. With respect to a specified agreement for which an applicable State authority has made a determination under the preceding sentence an applicable State authority may determine whether renewal of the contract, within the applicable 10-year period, is allowed. ; and by redesignating paragraph
(5)of subsection
(a)as subsection (c), adjusting the margin of such subsection accordingly, and transferring such subsection
(c)to appear after subsection (b), as added by subparagraph (A). Section 724 of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1185m ) is amended— by adding at the end the following: A group health plan or a health insurance issuer offering group health insurance coverage shall not enter into an agreement with a provider, network or association of providers, or other service provider offering access to a network of service providers if such agreement, directly or indirectly— restricts the group health plan or health insurance issuer from— directing or steering enrollees to other health care providers; or offering incentives to encourage enrollees to utilize specific health care providers; requires the group health plan or health insurance issuer to enter into any additional contract with an affiliate of the provider as a condition of entering into a contract with such provider; requires the group health plan or health insurance issuer to agree to payment rates or other terms for any affiliate not party to the contract of the provider involved; or restricts other group health plans or health insurance issuers not party to the contract from paying a lower rate for items or services than the contracting plan or issuer pays for such items or services. A self-insured group health plan shall not enter into an agreement with a provider, network or association of providers, third-party administrator, or other service provider offering access to a network of providers if such agreement directly or indirectly requires the group health plan to certify, attest, or otherwise confirm in writing that the group health plan is bound by restrictive contracting terms between the service provider and a third-party administrator that the group health plan is not party to, without a disclosure that such terms exist. Paragraph (1)(A) shall not apply to a group health plan or health insurance issuer offering group health insurance coverage with respect to— a health maintenance organization (as defined in section 733(b)(3)), if such health maintenance organization operates primarily through exclusive contracts with multi-specialty physician groups, nor to any arrangement between such a health maintenance organization and its affiliates; or a value-based network arrangement, such as an exclusive provider network, accountable care organization, center of excellence, a provider sponsored health insurance issuer that operates primarily through aligned multi-specialty physician group practices or integrated health systems, or such other similar network arrangements as determined by the Secretary through rulemaking. A group health plan or health insurance issuer offering group health insurance coverage shall annually submit to, as applicable, the applicable authority described in section 2723 of the Public Health Service Act or the Secretary of Labor or the Secretary of the Treasury, an attestation that such plan or issuer is in compliance with the requirements of this subsection. Nothing in this subsection shall be construed to limit network design or cost or quality initiatives by a group health plan or health insurance issuer, including accountable care organizations, exclusive provider organizations, networks that tier providers by cost or quality or steer enrollees to centers of excellence, or other pay-for-performance programs. Compliance with this subsection does not constitute compliance with the antitrust laws, as defined in subsection
(a)of the first section of the Clayton Act ( 15 U.S.C. 12(a) ). An applicable State authority may make a determination that the prohibitions under paragraph
(1)(with respect to conditions that would direct or steer to, or offer incentives to encourage enrollees to use, other health care providers) will not apply in the State with respect to any specified agreement that is executed before the date of enactment of the Bipartisan Primary Care and Health Workforce Act , for a maximum length of nonapplicability of up to 10 years from the date of execution of the contract if the applicable State authority determines that the contract is unlikely to significantly lessen competition. With respect to a specified agreement for which an applicable State authority has made a determination under the preceding sentence an applicable State authority may determine whether renewal of the contract, within the applicable 10-year period, is allowed. ; and by redesignating paragraph
(4)of subsection
(a)as subsection (c), adjusting the margin of such subsection accordingly, and transferring such subsection
(c)to appear after subsection (b), as added by subparagraph (A). Section 9824 of the Internal Revenue Code of 1986 is amended— by adding at the end the following: A group health plan shall not enter into an agreement with a provider, network or association of providers, or other service provider offering access to a network of service providers if such agreement, directly or indirectly— restricts the group health plan from— directing or steering enrollees to other health care providers; or offering incentives to encourage enrollees to utilize specific health care providers; requires the group health plan to enter into any additional contract with an affiliate of the provider as a condition of entering into a contract with such provider; requires the group health plan to agree to payment rates or other terms for any affiliate not party to the contract of the provider involved; or restricts other group health plans not party to the contract from paying a lower rate for items or services than the contracting plan pays for such items or services. A self-insured group health plan shall not enter into an agreement with a provider, network or association of providers, third-party administrator, or other service provider offering access to a network of providers if such agreement directly or indirectly requires the group health plan to certify, attest, or otherwise confirm in writing that the group health plan is bound by restrictive contracting terms between the service provider and a third-party administrator that the group health plan is not party to, without a disclosure that such terms exist. Paragraph (1)(A) shall not apply to a group health plan with respect to— a health maintenance organization (as defined in section 9832(b)(3)), if such health maintenance organization operates primarily through exclusive contracts with multi-specialty physician groups, nor to any arrangement between such a health maintenance organization and its affiliates; or a value-based network arrangement, such as an exclusive provider network, accountable care organization, center of excellence, a provider sponsored health insurance issuer that operates primarily through aligned multi-specialty physician group practices or integrated health systems, or such other similar network arrangements as determined by the Secretary through rulemaking. A group health plan shall annually submit to, as applicable, the applicable authority described in section 2723 of the Public Health Service Act or the Secretary of Labor or the Secretary of the Treasury, an attestation that such plan is in compliance with the requirements of this subsection. Nothing in this subsection shall be construed to limit network design or cost or quality initiatives by a group health plan, including accountable care organizations, exclusive provider organizations, networks that tier providers by cost or quality or steer enrollees to centers of excellence, or other pay-for-performance programs. Compliance with this subsection does not constitute compliance with the antitrust laws, as defined in subsection
(a)of the first section of the Clayton Act ( 15 U.S.C. 12(a) ). An applicable State authority may make a determination that the prohibitions under paragraph
(1)(with respect to conditions that would direct or steer to, or offer incentives to encourage enrollees to use, other health care providers) will not apply in the State with respect to any specified agreement that is executed before the date of enactment of the Bipartisan Primary Care and Health Workforce Act , for a maximum length of nonapplicability of up to 10 years from the date of execution of the contract if the applicable State authority determines that the contract is unlikely to significantly lessen competition. With respect to a specified agreement for which an applicable State authority has made a determination under the preceding sentence an applicable State authority may determine whether renewal of the contract, within the applicable 10-year period, is allowed. ; and by redesignating paragraph
(4)of subsection
(a)as subsection (c), adjusting the margin of such subsection accordingly, and transferring such subsection
(c)to appear after subsection (b), as added by subparagraph (A). Not later than 1 year after the date of enactment of this Act, the Secretary of Health and Human Services, the Secretary of Labor, and the Secretary of the Treasury, jointly, shall promulgate regulations to carry out section 2799A–9(b) of the Public Health Service Act, section 724(b) of the Employee Retirement Income Security Act of 1974, and section 9824(b) of the Internal Revenue Code of 1986, as added by subsection (a). Subsection
(b)of section 2799A–9 of the Public Health Service Act, subsection
(b)of section 724 of the Employee Retirement Income Security Act of 1974, and subsection
(b)of section 9824 of the Internal Revenue Code of 1986 (as added by paragraphs (1), (2), and (3), respectively, of subsection (a)) shall apply with respect to any contract entered into on or after the date that is 18 months after the date of enactment of this Act. With respect to an applicable contract that is in effect on the date of enactment of this Act, such subsection
(b)shall apply on the earlier of the date of renewal of such contract or 3 years after such date of enactment.
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- 42 USC 300gg–119
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Sec. 301
Banning anticompetitive terms in facility and insurance contracts that limit access to higher quality, lower cost care
Cite42 USC 300gg–119
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