“A bill to ban anticompetitive terms in facility and insurance contracts that limit access to higher quality, lower cost care.”
No CRS summary available for this bill.
This section amends sec. 724 of the Employee Retirement Income Security Act of 1974 (ERISA) (29 U.S.C. 1185m), which prohibits group health plans and health insurance issuers from entering contracts that restrict plan sponsors', enrollees', and providers' access to provider-specific cost and quality information and de-identified claims data. The amendments change the section heading to "; prohibition on anticompetitive agreements"; make a conforming change in subsection (a)(4); and add new subsection (b) to prohibit such plans and issuers from entering agreements with a covered entity (i.e., health care provider, network or association of providers, third-party administrator, or other service provider offering network access) that directly or indirectly— (1) restrict the plan or issuer from directing or steering enrollees to other providers or offering incentives to use specific providers; (2) require the plan or issuer to enter an additional agreement with an affiliate of the covered entity; (3) require the plan or issuer to agree to payment rates or terms for such an affiliate; or (4) restrict other plans or issuers from paying lower rates for the same items or services. New subsection (b) excepts from the steering prohibition health maintenance organizations operating primarily through exclusive multi-specialty physician group contracts and certain value-based arrangements (e.g., accountable care organizations, centers of excellence, provider-sponsored health insurance issuers with aligned physician groups, or integrated health systems, as determined by the Secretary). It allows states to grandfather specified agreements executed on June 19, 2019, and related agreements through December 31, 2020, for up to 10 years if unlikely to lessen competition significantly, with state authority over renewals; and includes a rule of construction preserving plans' network design and cost/quality initiatives (e.g., tiered networks, pay-for-performance). (Thus, the amendments enable plans greater flexibility to promote lower-cost, higher-quality care while curbing provider leverage via all-or-nothing, most-favored-nation, or affiliate-tying contract terms.)