§9824 — Title 26 Internal Revenue Code | U.S. Code

Summary

Group health plans must not make deals that stop them from sharing or getting provider-specific price or quality information. Plans must be able to give that information to referring doctors, the employer or plan sponsor, people covered by the plan, and people eligible to join. Plans must also be able to electronically get de-identified claims and encounter data for each person in the plan, if they ask and follow the privacy rules under section 264(c) of the Health Insurance Portability and Accountability Act of 1996, the Genetic Information Nondiscrimination Act of 2008, and the Americans with Disabilities Act of 1990. That per-claim data can include money details like the allowed amount or other payment obligations in the provider contract, the provider’s name and clinical role, service codes, and other claim elements. Plans may share the data with a business associate as defined in 45 C.F.R. §160.103 if they follow the privacy rules. Health care providers and networks may place reasonable limits on public release of the information. Each group health plan must annually tell the Secretary that it is following these requirements. Nothing here changes existing federal or state privacy protections or limits data access allowed under the cited privacy rules.

Title 26, §9824

Internal Revenue Code — Source: USLM XML via OLRC

(a)(1)A group health plan may not enter into an agreement with a health care provider, network or association of providers, third-party administrator, or other service provider offering access to a network of providers that would directly or indirectly restrict a group health plan from—

(A)providing provider-specific cost or quality of care information or data, through a consumer engagement tool or any other means, to referring providers, the plan sponsor, participants or beneficiaries, or individuals eligible to become participants or beneficiaries of the plan;

(B)electronically accessing de-identified claims and encounter information or data for each participant or beneficiary in the plan, upon request and consistent with the privacy regulations promulgated pursuant to section 264(c) of the Health Insurance Portability and Accountability Act of 1996, the amendments made by the Genetic Information Nondiscrimination Act of 2008, and the Americans with Disabilities Act of 1990, including, on a per claim basis—

(i)financial information, such as the allowed amount, or any other claim-related financial obligations included in the provider contract;

(ii)provider information, including name and clinical designation;

(iii)service codes; or

(iv)any other data element included in claim or encounter transactions; or

(C)sharing information or data described in subparagraph (A) or (B), or directing that such data be shared, with a business associate as defined in section 160.103 of title 45, Code of Federal Regulations (or successor regulations), consistent with the privacy regulations promulgated pursuant to section 264(c) of the Health Insurance Portability and Accountability Act of 1996, the amendments made by the Genetic Information Nondiscrimination Act of 2008, and the Americans with Disabilities Act of 1990.

(2)Nothing in paragraph (1)(A) prevents a health care provider, network or association of providers, or other service provider from placing reasonable restrictions on the public disclosure of the information described in such paragraph (1).

(3)A group health plan shall annually submit to the Secretary an attestation that such plan is in compliance with the requirements of this subsection.

(4)Nothing in this section shall be construed to modify or eliminate existing privacy protections and standards under State and Federal law. Nothing in this subsection shall be construed to otherwise limit access by a group health plan or plan sponsor to data as permitted under the privacy regulations promulgated pursuant to section 264(c) of the Health Insurance Portability and Accountability Act of 1996, the amendments made by the Genetic Information Nondiscrimination Act of 2008, and the Americans with Disabilities Act of 1990.

Notes & Related Subsidiaries

Editorial Notes

References in Text

section 264(c) of the Health Insurance Portability and Accountability Act of 1996, referred to in subsec. (a)(1)(B), (C), (4), is section 264 of Pub. L. 104–191, which is set out as a note under section 1320d–2 of Title 42, The Public Health and Welfare. The Genetic Information Nondiscrimination Act of 2008, referred to in subsec. (a)(1)(B), (C), (4), is Pub. L. 110–233, May 21, 2008, 122 Stat. 881. For complete classification of this Act to the Code, see

Short Title

note set out under section 2000ff of Title 42, The Public Health and Welfare, and Tables. The Americans with Disabilities Act of 1990, referred to in subsec. (a)(1)(B), (C), (4), is Pub. L. 101–336, July 26, 1990, 104 Stat. 327, which is classified principally to chapter 126 (§ 12101 et seq.) of Title 42, The Public Health and Welfare. For complete classification of this Act to the Code, see

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note set out under section 12101 of Title 42 and Tables.

§9824 Increasing Transparency by Removing Gag Clauses on Price and Quality Information

Summary

Title 26, §9824

Notes & Related Subsidiaries

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References in Text

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