42 U.S.C. § 300gg–119: Increasing transparency…

Summary

Health plans and insurers must not sign contracts with provider networks or service vendors that stop them from sharing provider-specific price or quality information with referring doctors, plan sponsors, enrollees, or people who could enroll. For group plans, they also must be allowed to get, electronically, de-identified claims and encounter data for each enrollee on a per-claim basis, including financial items (like the allowed amount or other claim payments), provider name and clinical role, service codes, and any other data in a claim. Both group and individual issuers may share the price or quality data with a business associate (as defined at 45 CFR 160.103) when doing plan design, administration, financial, legal, or quality improvement work, as long as they 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. Providers or networks can put reasonable limits on how the information is publicly released. Each group plan and each issuer offering group or individual coverage must file a yearly statement with the Secretary saying they follow these rules. Nothing here changes existing state or federal privacy protections or reduces access to data allowed under the cited privacy regulations.

Title 42, §300gg–119

The Public Health and Welfare, Source: USLM XML via OLRC

(a)Increasing price and quality transparency for plan sponsors and group and individual market consumers

(1)Group health plans

A group health plan or health insurance issuer offering group health insurance coverage 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 or health insurance issuer offering such coverage 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, enrollees, or individuals eligible to become enrollees of the plan or coverage;

(B)electronically accessing de-identified claims and encounter information or data for each enrollee in the plan or coverage, 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 [42 U.S.C. 12101 et seq.], 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 [42 U.S.C. 12101 et seq.].

(2)Individual health insurance coverage

A health insurance issuer offering individual health insurance coverage may not enter into an agreement with a health care provider, network or association of providers, or other service provider offering access to a network of providers that would directly or indirectly restrict the health insurance issuer from—

(A)providing provider-specific price or quality of care information, through a consumer engagement tool or any other means, to referring providers, enrollees, or individuals eligible to become enrollees of the plan or coverage; or

(B)sharing, for plan design, plan administration, and plan, financial, legal, and quality improvement activities, data described in subparagraph (A) 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 [42 U.S.C. 12101 et seq.].

(3)Clarification regarding public disclosure of information

Nothing in paragraph (1)(A) or (2)(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 paragraphs (1) and (2).

(4)Attestation

A group health plan or a health insurance issuer offering group or individual 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.

(5)Rules of construction

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, plan sponsor, or health insurance issuer 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 [42 U.S.C. 12101 et seq.].

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), (2)(B), (5), is section 264 of Pub. L. 104–191, which is set out as a note under section 1320d–2 of this title. The Genetic Information Nondiscrimination Act of 2008, referred to in subsec. (a)(1)(B), (C), (2)(B), (5), 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 this title and Tables. The Americans with Disabilities Act of 1990, referred to in subsec. (a)(1)(B), (C), (2)(B), (5), is Pub. L. 101–336, July 26, 1990, 104 Stat. 327, which is classified principally to chapter 126 (§ 12101 et seq.) of this title. For complete classification of this Act to the Code, see

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note set out under section 12101 of this title and Tables.

§300gg–119 Increasing Transparency by Removing Gag Clauses on Price and Quality Information

Summary

Title 42, §300gg–119

Notes & Related Subsidiaries

Editorial Notes

References in Text

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