Sec. 7. Increasing group health plan access to health data
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Paragraph
(2)of section 408(b) of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1108(b) ) is amended by adding at the end the following new subparagraphs: No contract or arrangement for services between a group health plan and any other entity, including a health care provider (including a health care facility), network or association of providers, service provider offering access to a network of providers, third-party administrator, or pharmacy benefit manager (collectively, Covered Service Providers ), is reasonable within the meaning of this paragraph unless such contract or arrangement— allows the responsible group health plan access to all claims and encounter information, and any documentation supporting claim payments, including, but not limited to, medical records and policy documents, or data described in section 724(a)(1)(B) to— enable such entity to comply with the terms of the plan and any applicable law; and determine the accuracy or reasonableness of payment; and does not— unreasonably limit or delay access to such information or data; limit the volume of claims and encounter information or data that the group health plan may access during an audit; limit the disclosure of pricing terms for value-based payment arrangements or capitated payment arrangements, including— payment calculations and formulas; quality measures; contract terms; payment amounts; measurement periods for all incentives; and other payment methodologies used by an entity, including a health care provider (including a health care facility), network or association of providers, service provider offering access to a network of providers, third-party administrator, or pharmacy benefit manager; limit the disclosure of overpayments and overpayment recovery terms; limit the right of the group health plan to select an auditor or define audit scope or frequency; otherwise limit or unduly delay the group health plan from accessing claims and encounter information or data in a daily batch. limit the disclosure of fees charged to the group health plan related to plan administration and claims processing, including renegotiation fees, access fees, repricing fees, or enhanced review fees; limit the right of the group health plan to request action on any suspect claim payments; or limit public disclosure of de-identified or aggregate information. Covered Service Providers shall provide information under this paragraph in a manner consistent with the privacy and security regulations promulgated under the Health Insurance Portability and Accountability Act (HIPAA). This subparagraph shall not be read to abridge or limit the disclosure requirements under this paragraph or to impose additional privacy or security requirements on Covered Service Providers or plan sponsors. A group health plan receiving information or data under this paragraph may disclose such information only to the entity from which the information or data was received, the group health plan or plan sponsor to which the information or data pertains, or to that entity’s business associates as defined in section 160.103 of title 45, Code of Federal Regulations, or as otherwise permitted by the HIPAA Privacy Rule (45 CFR parts 160 and 164, subparts A and E). Information made available under this section shall conform to the following standards: Institutional, professional, and dental claims received from a healthcare provider shall be made available to the group health plan as ASC X12N 837 files. The files shall be unmodified copies of the files sent from the provider. In the event that paper claims are sent by the provider, they shall be converted to the ASC X12N 837 electronic format. Files shall be accessible to the plan at no cost to the group health plan. All claim payment (or EFT, electronic funds transfer) and electronic remittance advice
(ERA)notices sent by a Covered Service Provider shall be made available to the group health plan as ASC X12N 835 files. The files shall be unmodified copies of the files sent by the Covered Service Provider to the healthcare provider. Files shall be accessible at no cost to the group health plan. The contractual terms containing calculation formulae, pricing methodologies, and other information used to determine the dollar value of reimbursement. All non-claim costs shall be itemized and made available to the group health plan in real time through a web-based portal, through an API, and through a downloadable CSV file. . Subsection
(c)of section 502 of such Act ( 29 U.S.C. 1132 ) is amended by adding at the end the following new paragraph: ‘‘(13) In the case of an agreement between a group health plan and a health care provider (including a health care facility), network or association of providers, service provider offering access to a network of providers, third-party administrator, or pharmacy benefit manager, that violates the provisions of section 724, the Secretary may assess a civil penalty against such provider, network or association, service provider offering access to a network of providers, third-party administrator, pharmacy benefit manager, or other service provider in the amount of $10,000 for each day during which such violation continues. Such penalty shall be in addition to other penalties as may be prescribed by law. Paragraph
(6)of section 502(a) of such Act is amended by striking or
(9)and inserting (9), or
(13). Section 410 of such Act is amended by adding at the end the following: Any provision in an agreement or instrument shall be void as against public policy if such provision— unduly delays or limits a group health plan from accessing the claims and encounter information or data described in section 724(a)(1)(B); or violates the requirements of section 408(b)(2)(C). . Clause
(i)of section 408(b)(2)(B) of such Act is amended by striking this clause and inserting this paragraph . Section 724(a)(3) of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1185m(a)(3) ) is amended to read as follows: Subject to subparagraph (C), the group health plan or health insurance issuer offering group health insurance coverage shall annually submit to the Secretary an attestation that such plan or issuer of such coverage is in compliance with the requirements of this subsection. Such attestation shall also include a statement verifying that— the information or data described under subparagraphs
(A)and
(B)of paragraph
(1)is available upon request and provided to the group health plan, the plan administrator, or the issuer in a timely manner; and there are no terms in the agreement under such paragraph
(1)that directly or indirectly restrict or unduly delay a group health plan, the plan administrator, or the issuer from auditing, reviewing, or otherwise accessing such information, except as permitted under section 408(b)(2)(C). Subject to clause (ii), a group health plan or issuer offering group health insurance coverage may not enter into an agreement with a third-party administrator or other service provider to submit the attestation required under subparagraph (A). In the case of a group health plan or issuer offering group health insurance coverage that is unable to obtain the information or data needed to submit the attestation required under subparagraph (A), such plan or issuer may submit a written statement in lieu of such attestation that includes— an explanation of why such plan or issuer was unsuccessful in obtaining such information or data, including whether such plan or issuer was limited or prevented from auditing, reviewing, or otherwise accessing such information or data; a description of the efforts made by the group health plan to remove any gag clause provisions from the agreement under paragraph (1); and a description of any response by the third-party administrator or other service provider with respect to efforts to comply with the attestation requirement under subparagraph (A). . The amendments made by subsections
(a)and
(b)shall apply with respect to a plan beginning with the first plan year that begins on or after the date that is 1 year after the date of enactment of this Act.
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