1 | 1 | | I |
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2 | 2 | | 119THCONGRESS |
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3 | 3 | | 1 |
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4 | 4 | | STSESSION H. R. 2041 |
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5 | 5 | | To amend the Employee Retirement Income Security Act of 1974 to clarify |
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6 | 6 | | and strengthen the application of certain employer-sponsored health plan |
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7 | 7 | | disclosure requirements. |
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8 | 8 | | IN THE HOUSE OF REPRESENTATIVES |
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9 | 9 | | MARCH11, 2025 |
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10 | 10 | | Mr. C |
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11 | 11 | | OURTNEY(for himself and Mrs. HOUCHIN) introduced the following bill; |
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12 | 12 | | which was referred to the Committee on Education and Workforce |
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13 | 13 | | A BILL |
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14 | 14 | | To amend the Employee Retirement Income Security Act |
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15 | 15 | | of 1974 to clarify and strengthen the application of |
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16 | 16 | | certain employer-sponsored health plan disclosure re- |
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17 | 17 | | quirements. |
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18 | 18 | | Be it enacted by the Senate and House of Representa-1 |
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19 | 19 | | tives of the United States of America in Congress assembled, 2 |
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20 | 20 | | SECTION 1. SHORT TITLE. 3 |
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21 | 21 | | This Act may be cited as the ‘‘Hidden Fee Disclosure 4 |
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22 | 22 | | Act of 2025’’. 5 |
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24 | 24 | | ssavage on LAPJG3WLY3PROD with BILLS 2 |
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25 | 25 | | •HR 2041 IH |
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26 | 26 | | SEC. 2. CLARIFICATION OF THE APPLICATION OF FEE DIS-1 |
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27 | 27 | | CLOSURE REQUIREMENTS TO COVERED 2 |
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28 | 28 | | SERVICE PROVIDERS. 3 |
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29 | 29 | | (a) S |
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30 | 30 | | ERVICES.—Clause (ii)(I)(bb) of section 4 |
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31 | 31 | | 408(b)(2)(B) of the Employee Retirement Income Secu-5 |
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32 | 32 | | rity Act of 1974 (29 U.S.C. 1108(b)(2)(B)) is amended— 6 |
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33 | 33 | | (1) in subitem (AA) by striking ‘‘Brokerage 7 |
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34 | 34 | | services,’’ and inserting ‘‘Services (including broker-8 |
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35 | 35 | | age services),’’; and 9 |
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36 | 36 | | (2) in subitem (BB)— 10 |
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37 | 37 | | (A) by striking ‘‘Consulting,’’ and inserting 11 |
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38 | 38 | | ‘‘Other services,’’; and 12 |
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39 | 39 | | (B) by striking ‘‘related to the development 13 |
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40 | 40 | | or implementation of plan design’’ and all that 14 |
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41 | 41 | | follows through the period at the end and in-15 |
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42 | 42 | | serting ‘‘any of the following: plan design, claim 16 |
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43 | 43 | | repricing, insurance or insurance product selec-17 |
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44 | 44 | | tion (including vision and dental), record-18 |
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45 | 45 | | keeping, medical management, benefits adminis-19 |
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46 | 46 | | tration selection (including vision and dental), 20 |
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47 | 47 | | stop-loss insurance, pharmacy benefit manage-21 |
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48 | 48 | | ment services, wellness design and management 22 |
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49 | 49 | | services, transparency tools, group purchasing 23 |
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50 | 50 | | organization agreements and services, participa-24 |
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51 | 51 | | tion in and services from preferred vendor pan-25 |
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52 | 52 | | els, disease management, compliance services, 26 |
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54 | 54 | | ssavage on LAPJG3WLY3PROD with BILLS 3 |
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55 | 55 | | •HR 2041 IH |
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56 | 56 | | employee assistance programs, or third party 1 |
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57 | 57 | | administration services, or consulting services 2 |
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58 | 58 | | related to any such services.’’. 3 |
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59 | 59 | | (b) D |
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60 | 60 | | ISCLOSURES.—Clause (iii)(III) of section 4 |
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61 | 61 | | 408(b)(2)(B) of the Employee Retirement Income Secu-5 |
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62 | 62 | | rity Act of 1974 (29 U.S.C. 1108(b)(2)(B)) is amended 6 |
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63 | 63 | | by striking ‘‘, either in the aggregate or by service,’’ and 7 |
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64 | 64 | | inserting ‘‘by service’’. 8 |
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65 | 65 | | SEC. 3. STRENGTHENING DISCLOSURE REQUIREMENTS 9 |
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66 | 66 | | WITH RESPECT TO ENTITIES PROVIDING 10 |
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67 | 67 | | PHARMACY BENEFIT MANAGEMENT SERV-11 |
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68 | 68 | | ICES AND THIRD PARTY ADMINISTRATORS 12 |
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69 | 69 | | FOR GROUP HEALTH PLANS. 13 |
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70 | 70 | | (a) C |
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71 | 71 | | ERTAINARRANGEMENTS FOR PHARMACYBEN-14 |
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72 | 72 | | EFITMANAGEMENT SERVICESCONSIDERED AS INDI-15 |
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73 | 73 | | RECT.— 16 |
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74 | 74 | | (1) I |
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75 | 75 | | N GENERAL.—Clause (i) of section 17 |
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76 | 76 | | 408(b)(2)(B) of the Employee Retirement Income 18 |
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77 | 77 | | Security Act of 1974 (29 U.S.C. 1108(b)(2)(B)) is 19 |
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78 | 78 | | amended— 20 |
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79 | 79 | | (A) by striking ‘‘requirements of this 21 |
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80 | 80 | | clause’’ and inserting ‘‘requirements of this 22 |
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81 | 81 | | subparagraph’’; and 23 |
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82 | 82 | | (B) by adding at the end the following: 24 |
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83 | 83 | | ‘‘For purposes of applying section 406(a)(1)(C) 25 |
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85 | 85 | | ssavage on LAPJG3WLY3PROD with BILLS 4 |
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86 | 86 | | •HR 2041 IH |
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87 | 87 | | with respect to a transaction described under 1 |
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88 | 88 | | this subparagraph, a contract or arrangement 2 |
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89 | 89 | | for services between a covered plan and an enti-3 |
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90 | 90 | | ty or subsidiary providing services to the plan, 4 |
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91 | 91 | | including a health insurance issuer providing 5 |
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92 | 92 | | health insurance coverage in connection with 6 |
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93 | 93 | | the covered plan in which the entity or sub-7 |
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94 | 94 | | sidiary contracts, in connection with such plan, 8 |
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95 | 95 | | with a service provider for pharmacy benefit 9 |
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96 | 96 | | management services shall be considered an in-10 |
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97 | 97 | | direct furnishing of goods, services, or facilities 11 |
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98 | 98 | | between the covered plan and the service pro-12 |
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99 | 99 | | vider for pharmacy benefit management services 13 |
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100 | 100 | | acting as the party in interest.’’. 14 |
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101 | 101 | | (2) H |
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102 | 102 | | EALTH INSURANCE ISSUER AND HEALTH 15 |
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103 | 103 | | INSURANCE COVERAGE DEFINED .—Clause (ii)(I)(aa) 16 |
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104 | 104 | | of section 408(b)(2)(B) of the Employee Retirement 17 |
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105 | 105 | | Income Security Act of 1974 (29 U.S.C. 18 |
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106 | 106 | | 1108(b)(2)(B)) is amended by inserting before the 19 |
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107 | 107 | | period at the end ‘‘and the terms ‘health insurance 20 |
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108 | 108 | | coverage’ and ‘health insurance issuer’ have the 21 |
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109 | 109 | | meanings given such terms in section 733(b)’’. 22 |
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110 | 110 | | (3) T |
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111 | 111 | | ECHNICAL AMENDMENT .—Section 23 |
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112 | 112 | | 408(b)(2)(B)(ii)(I)(aa) of the Employee Retirement 24 |
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113 | 113 | | Income Security Act of 1974 (29 U.S.C. 25 |
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115 | 115 | | ssavage on LAPJG3WLY3PROD with BILLS 5 |
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116 | 116 | | •HR 2041 IH |
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117 | 117 | | 1108(b)(2)(B)(ii)(I)(aa)) is further amended by in-1 |
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118 | 118 | | serting ‘‘in’’ after ‘‘defined’’. 2 |
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119 | 119 | | (b) S |
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120 | 120 | | PECIFICDISCLOSUREREQUIREMENTS WITH 3 |
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121 | 121 | | R |
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122 | 122 | | ESPECT TOENTITIESPROVIDINGPHARMACYBENEFIT 4 |
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123 | 123 | | M |
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124 | 124 | | ANAGEMENTSERVICES.— 5 |
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125 | 125 | | (1) I |
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126 | 126 | | N GENERAL.—Clause (iii) of section 6 |
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127 | 127 | | 408(b)(2)(B) of such Act (29 U.S.C. 1108(b)(2)(B)) 7 |
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128 | 128 | | is amended by adding at the end the following: 8 |
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129 | 129 | | ‘‘(VII) In the case of a covered service pro-9 |
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130 | 130 | | vider in a contract or arrangement with a cov-10 |
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131 | 131 | | ered plan to provide pharmacy benefit manage-11 |
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132 | 132 | | ment services, as part of the description re-12 |
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133 | 133 | | quired under subclauses (III) and (IV)— 13 |
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134 | 134 | | ‘‘(aa) all compensation described in 14 |
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135 | 135 | | clause (ii)(I)(dd)(AA), including fees, re-15 |
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136 | 136 | | bates, alternative discounts, price conces-16 |
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137 | 137 | | sions, co-payment offsets, and other remu-17 |
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138 | 138 | | neration reasonably expected to be received 18 |
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139 | 139 | | by the covered service provider, an affil-19 |
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140 | 140 | | iate, or a subcontractor from a drug manu-20 |
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141 | 141 | | facturer, distributor, rebate aggregator, ac-21 |
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142 | 142 | | cumulator, maximizer, group purchasing 22 |
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143 | 143 | | organization, or any other third party; 23 |
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144 | 144 | | ‘‘(bb) the amount and form of any 24 |
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145 | 145 | | fees, rebates, alternative discounts, price 25 |
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147 | 147 | | ssavage on LAPJG3WLY3PROD with BILLS 6 |
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148 | 148 | | •HR 2041 IH |
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149 | 149 | | concessions, co-payment offsets, and other 1 |
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150 | 150 | | remuneration, including the amount ex-2 |
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151 | 151 | | pected to be passed through to the plan 3 |
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152 | 152 | | sponsor or the participants and bene-4 |
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153 | 153 | | ficiaries under the covered plan; 5 |
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154 | 154 | | ‘‘(cc) all compensation reasonably ex-6 |
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155 | 155 | | pected to be received by the covered service 7 |
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156 | 156 | | provider, an affiliate, or a subcontractor as 8 |
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157 | 157 | | a result of paying a lower amount for the 9 |
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158 | 158 | | drug than the amount charged as a copay-10 |
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159 | 159 | | ment, coinsurance amount, or deductible; 11 |
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160 | 160 | | ‘‘(dd) all compensation expected to be 12 |
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161 | 161 | | received by the covered service provider, an 13 |
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162 | 162 | | affiliate, or a subcontractor as a result of 14 |
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163 | 163 | | paying pharmacies less than the amount 15 |
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164 | 164 | | charged to the health plan, plan sponsor, 16 |
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165 | 165 | | or participants and beneficiaries (com-17 |
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166 | 166 | | monly referred to as ‘spread pricing’); 18 |
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167 | 167 | | ‘‘(ee) all compensation expected to be 19 |
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168 | 168 | | received by the covered service provider, an 20 |
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169 | 169 | | affiliate, or a subcontractor from drug 21 |
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170 | 170 | | manufacturers or any other third party in 22 |
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171 | 171 | | exchange for— 23 |
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174 | 174 | | •HR 2041 IH |
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175 | 175 | | ‘‘(AA) administering, invoicing, 1 |
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176 | 176 | | allocating, or collecting rebates related 2 |
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177 | 177 | | to the covered plan; 3 |
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178 | 178 | | ‘‘(BB) providing access to drug 4 |
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179 | 179 | | utilization data; 5 |
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180 | 180 | | ‘‘(CC) retaining a percentage of 6 |
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181 | 181 | | the list price of a drug; or 7 |
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182 | 182 | | ‘‘(DD) any other service related 8 |
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183 | 183 | | to the role of the covered service pro-9 |
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184 | 184 | | vider as a conduit between the drug 10 |
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185 | 185 | | manufacturers or any other third 11 |
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186 | 186 | | party and the covered plan.’’. 12 |
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187 | 187 | | (2) A |
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188 | 188 | | NNUAL DISCLOSURE .—Clause (v) of sec-13 |
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189 | 189 | | tion 408(b)(2)(B) of such Act (29 U.S.C. 14 |
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190 | 190 | | 1108(b)(2)(B)) is amended by adding at the end the 15 |
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191 | 191 | | following: 16 |
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192 | 192 | | ‘‘(III) A covered service provider, with respect 17 |
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193 | 193 | | to a contract or arrangement with the covered plan 18 |
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194 | 194 | | in connection with providing pharmacy benefit man-19 |
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195 | 195 | | agement services, shall disclose, on an annual basis 20 |
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196 | 196 | | not later than 60 days after the beginning of each 21 |
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197 | 197 | | plan year, to a responsible plan fiduciary, in writing, 22 |
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198 | 198 | | the following with respect to the preceding plan 23 |
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199 | 199 | | year: 24 |
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201 | 201 | | ssavage on LAPJG3WLY3PROD with BILLS 8 |
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202 | 202 | | •HR 2041 IH |
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203 | 203 | | ‘‘(aa) All direct compensation described in 1 |
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204 | 204 | | subclause (III) of clause (iii) and indirect com-2 |
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205 | 205 | | pensation described in subclause (IV) of clause 3 |
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206 | 206 | | (iii) received by the covered service provider (in-4 |
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207 | 207 | | cluding such compensation described in sub-5 |
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208 | 208 | | clause (VII) of clause (iii)). 6 |
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209 | 209 | | ‘‘(bb) The total gross spending by the cov-7 |
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210 | 210 | | ered plan on drugs (excluding fees rebates, al-8 |
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211 | 211 | | ternative discounts, price concessions, co-pay-9 |
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212 | 212 | | ment offsets, and other remuneration). 10 |
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213 | 213 | | ‘‘(cc) The total net spending by the cov-11 |
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214 | 214 | | ered plan on drugs. 12 |
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215 | 215 | | ‘‘(dd) The total gross spending on drugs at 13 |
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216 | 216 | | all pharmacies wholly or partially owned by the 14 |
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217 | 217 | | covered service provider or any entity affiliated 15 |
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218 | 218 | | with the covered service provider, including 16 |
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219 | 219 | | mail-order, specialty and retail pharmacies, with 17 |
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220 | 220 | | a breakdown by individual pharmacy location. 18 |
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221 | 221 | | ‘‘(ee) The aggregate amount of cost-shar-19 |
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222 | 222 | | ing collected by the covered service provider 20 |
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223 | 223 | | from a pharmacy for a participant or bene-21 |
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224 | 224 | | ficiary in excess of the contracted rate from 22 |
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225 | 225 | | such pharmacies, including mail-order, spe-23 |
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226 | 226 | | cialty, and retail pharmacies, including— 24 |
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228 | 228 | | ssavage on LAPJG3WLY3PROD with BILLS 9 |
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229 | 229 | | •HR 2041 IH |
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230 | 230 | | ‘‘(AA) categorical explanations 1 |
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231 | 231 | | (grouped by the reason for collection of 2 |
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232 | 232 | | such amounts, such as contractual true-up 3 |
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233 | 233 | | provisions, overpayments, or non-covered 4 |
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234 | 234 | | medication dispensed, and including infor-5 |
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235 | 235 | | mation on the amount in each category 6 |
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236 | 236 | | that was passed through to the covered 7 |
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237 | 237 | | plan and to participants and beneficiaries 8 |
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238 | 238 | | of the covered plan); or 9 |
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239 | 239 | | ‘‘(BB) individual explanations for 10 |
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240 | 240 | | such amounts. 11 |
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241 | 241 | | ‘‘(ff) Total aggregate amounts of fees col-12 |
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242 | 242 | | lected by the covered service provider, an affil-13 |
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243 | 243 | | iate, or a subcontractor in connection with the 14 |
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244 | 244 | | provision of pharmacy benefit management 15 |
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245 | 245 | | services to the covered plan, broken down by 16 |
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246 | 246 | | the source of such fees (such as the covered 17 |
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247 | 247 | | plan, participants and beneficiaries of the cov-18 |
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248 | 248 | | ered plan, any drug manufacturer or whole-19 |
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249 | 249 | | saler, or any pharmacy entity). 20 |
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250 | 250 | | ‘‘(gg) Any information specified by the 21 |
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251 | 251 | | Secretary through regulations or guidance that 22 |
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252 | 252 | | may be necessary for a responsible plan fidu-23 |
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253 | 253 | | ciary to determine the reasonableness of the 24 |
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254 | 254 | | contract or arrangement with the covered serv-25 |
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256 | 256 | | ssavage on LAPJG3WLY3PROD with BILLS 10 |
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257 | 257 | | •HR 2041 IH |
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258 | 258 | | ice provider, any compensation paid under such 1 |
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259 | 259 | | a contract or arrangement, or any conflicts of 2 |
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260 | 260 | | interest that may exist.’’. 3 |
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261 | 261 | | (3) P |
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262 | 262 | | HARMACY BENEFIT MANAGEMENT SERV -4 |
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263 | 263 | | ICES DEFINED .—Clause (ii)(I) of section 5 |
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264 | 264 | | 408(b)(2)(B) of such Act (29 U.S.C. 1108(b)(2)(B)) 6 |
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265 | 265 | | is amended by adding at the end the following: 7 |
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266 | 266 | | ‘‘(gg) The term ‘pharmacy benefit manage-8 |
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267 | 267 | | ment services’ includes any services provided by 9 |
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268 | 268 | | a covered service provider to a covered plan 10 |
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269 | 269 | | with respect to the administration of prescrip-11 |
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270 | 270 | | tion drug benefits under the covered plan, in-12 |
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271 | 271 | | cluding— 13 |
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272 | 272 | | ‘‘(AA) the processing and payment of 14 |
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273 | 273 | | claims; 15 |
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274 | 274 | | ‘‘(BB) design of pharmacy networks; 16 |
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275 | 275 | | ‘‘(CC) negotiation, aggregation, and 17 |
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276 | 276 | | distribution of rebates, discounts, and 18 |
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277 | 277 | | other price concessions; 19 |
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278 | 278 | | ‘‘(DD) formulary design and mainte-20 |
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279 | 279 | | nance; 21 |
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280 | 280 | | ‘‘(EE) operation of pharmacies 22 |
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281 | 281 | | (whether retail, mail order, specialty drug, 23 |
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282 | 282 | | or otherwise); recordkeeping; 24 |
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283 | 283 | | ‘‘(FF) utilization review; 25 |
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285 | 285 | | ssavage on LAPJG3WLY3PROD with BILLS 11 |
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286 | 286 | | •HR 2041 IH |
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287 | 287 | | ‘‘(GG) adjudication of claims; and 1 |
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288 | 288 | | ‘‘(HH) any other services specified by 2 |
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289 | 289 | | the Secretary through guidance or rule-3 |
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290 | 290 | | making.’’. 4 |
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291 | 291 | | (c) S |
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292 | 292 | | PECIFICDISCLOSUREREQUIREMENTS WITH 5 |
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293 | 293 | | R |
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294 | 294 | | ESPECT TOTHIRDPARTYADMINISTRATIONSERVICES 6 |
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295 | 295 | | FORGROUPHEALTHPLANS.— 7 |
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296 | 296 | | (1) I |
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297 | 297 | | N GENERAL.—Clause (iii) of section 8 |
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298 | 298 | | 408(b)(2)(B) of such Act (29 U.S.C. 9 |
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299 | 299 | | 1108(b)(2)(B)), as amended by subsection (b)(1), is 10 |
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300 | 300 | | further amended by adding at the end the following: 11 |
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301 | 301 | | ‘‘(VIII) With respect to a contract or ar-12 |
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302 | 302 | | rangement with the covered plan in connection 13 |
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303 | 303 | | with the provision of third party administration 14 |
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304 | 304 | | services for group health plans, as part of the 15 |
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305 | 305 | | description required under subclauses (III) and 16 |
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306 | 306 | | (IV)— 17 |
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307 | 307 | | ‘‘(aa) the amount and form of any re-18 |
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308 | 308 | | bates, discounts, savings fees, refunds, or 19 |
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309 | 309 | | amounts received from providers and facili-20 |
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310 | 310 | | ties, including the amounts that will be re-21 |
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311 | 311 | | tained by the covered service provider; 22 |
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312 | 312 | | ‘‘(bb) the amount and form of fees ex-23 |
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313 | 313 | | pected to be received from other service 24 |
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314 | 314 | | providers in relation to the covered plan, 25 |
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317 | 317 | | •HR 2041 IH |
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318 | 318 | | including the amounts that will be retained 1 |
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319 | 319 | | by the covered service provider as a fee, to 2 |
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320 | 320 | | the extent feasible; and 3 |
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321 | 321 | | ‘‘(cc) the amount and form of ex-4 |
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322 | 322 | | pected recoveries by the covered service 5 |
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323 | 323 | | provider, including the amounts that will 6 |
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324 | 324 | | be retained by the covered service provider 7 |
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325 | 325 | | (disaggregated by category), as a result 8 |
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326 | 326 | | of— 9 |
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327 | 327 | | ‘‘(AA) overpayments; 10 |
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328 | 328 | | ‘‘(BB) erroneous payments; 11 |
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329 | 329 | | ‘‘(CC) uncashed checks or incom-12 |
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330 | 330 | | plete payments; 13 |
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331 | 331 | | ‘‘(DD) billing errors; 14 |
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332 | 332 | | ‘‘(EE) subrogation; 15 |
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333 | 333 | | ‘‘(FF) fraud; or 16 |
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334 | 334 | | ‘‘(GG) any other reason on behalf 17 |
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335 | 335 | | of the covered plan.’’. 18 |
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336 | 336 | | (2) A |
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337 | 337 | | NNUAL DISCLOSURE .—Clause (v) of sec-19 |
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338 | 338 | | tion 408(b)(2)(B) of such Act (29 U.S.C. 20 |
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339 | 339 | | 1108(b)(2)(B)), as amended by subsection (b)(2), is 21 |
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340 | 340 | | amended by adding at the end the following: 22 |
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341 | 341 | | ‘‘(IV) A covered service provider, with respect 23 |
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342 | 342 | | to a contract or arrangement with the covered plan 24 |
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343 | 343 | | in connection with providing third party administra-25 |
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345 | 345 | | ssavage on LAPJG3WLY3PROD with BILLS 13 |
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346 | 346 | | •HR 2041 IH |
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347 | 347 | | tion services for group health plans, shall disclose, 1 |
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348 | 348 | | on an annual basis not later than 60 days after the 2 |
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349 | 349 | | beginning of each plan year, to a responsible plan fi-3 |
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350 | 350 | | duciary, in writing, the following with respect to the 4 |
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351 | 351 | | preceding plan year: 5 |
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352 | 352 | | ‘‘(aa) All direct compensation described in 6 |
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353 | 353 | | subclause (III) of clause (iii). 7 |
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354 | 354 | | ‘‘(bb) All indirect compensation described 8 |
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355 | 355 | | in subclause (IV) of clause (iii) received by the 9 |
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356 | 356 | | covered service provider, an affiliate, or a sub-10 |
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357 | 357 | | contractor (including such compensation de-11 |
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358 | 358 | | scribed in subclause (VIII) of clause (iii)). 12 |
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359 | 359 | | ‘‘(cc) The aggregate amount for which the 13 |
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360 | 360 | | covered service provider, an affiliate, or a sub-14 |
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361 | 361 | | contractor received indirect compensation and 15 |
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362 | 362 | | the estimated amount of cost-sharing incurred 16 |
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363 | 363 | | by plan participants and beneficiaries as a re-17 |
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364 | 364 | | sult. 18 |
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365 | 365 | | ‘‘(dd) The total gross spending by the cov-19 |
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366 | 366 | | ered plan on all costs and fees arising under or 20 |
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367 | 367 | | paid under the administrative services agree-21 |
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368 | 368 | | ment with the covered service provider (not in-22 |
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369 | 369 | | cluding any amounts described in items (aa) 23 |
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370 | 370 | | through (cc) of clause (iii)(VIII)). 24 |
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373 | 373 | | •HR 2041 IH |
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374 | 374 | | ‘‘(ee) The total net spending by the cov-1 |
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375 | 375 | | ered plan on all costs and fees arising under or 2 |
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376 | 376 | | paid under the administrative services agree-3 |
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377 | 377 | | ment with the covered service provider. 4 |
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378 | 378 | | ‘‘(ff) The aggregate fees collected by the 5 |
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379 | 379 | | covered service provider, an affiliate, or a sub-6 |
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380 | 380 | | contractor from any source. 7 |
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381 | 381 | | ‘‘(gg) Any other information specified by 8 |
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382 | 382 | | the Secretary through regulations or guidance 9 |
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383 | 383 | | that may be necessary for a responsible plan fi-10 |
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384 | 384 | | duciary to determine the reasonableness of the 11 |
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385 | 385 | | contract or arrangement with the covered serv-12 |
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386 | 386 | | ice provider any compensation paid under such 13 |
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387 | 387 | | a contractor or arrangement, or any conflicts of 14 |
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388 | 388 | | interest that may exist.’’. 15 |
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389 | 389 | | (3) T |
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390 | 390 | | HIRD PARTY ADMINISTRATION SERVICES 16 |
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391 | 391 | | FOR GROUP HEALTH PLANS DEFINED .—Clause 17 |
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392 | 392 | | (ii)(I) of section 408(b)(2)(B) of such Act (29 18 |
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393 | 393 | | U.S.C. 1108(b)(2)(B)), as amended by subsection 19 |
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394 | 394 | | (b)(3), is amended by adding at the end the fol-20 |
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395 | 395 | | lowing: 21 |
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396 | 396 | | ‘‘(hh) The term ‘third party administration 22 |
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397 | 397 | | services for group health plans’ includes any 23 |
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398 | 398 | | services provided by a covered service provider 24 |
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399 | 399 | | to a covered plan with respect to the adminis-25 |
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402 | 402 | | •HR 2041 IH |
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403 | 403 | | tration of health benefits under the covered 1 |
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404 | 404 | | plan, including— 2 |
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405 | 405 | | ‘‘(AA) the processing, repricing, and 3 |
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406 | 406 | | payment of claims; 4 |
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407 | 407 | | ‘‘(BB) design, creation, and mainte-5 |
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408 | 408 | | nance of provider networks; 6 |
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409 | 409 | | ‘‘(CC) negotiation of discounts off 7 |
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410 | 410 | | gross rates; 8 |
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411 | 411 | | ‘‘(DD) benefit and plan design; nego-9 |
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412 | 412 | | tiation of payment rates; 10 |
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413 | 413 | | ‘‘(EE) recordkeeping; 11 |
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414 | 414 | | ‘‘(FF) utilization review; 12 |
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415 | 415 | | ‘‘(GG) adjudication of claims; 13 |
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416 | 416 | | ‘‘(HH) regulatory compliance; and 14 |
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417 | 417 | | ‘‘(II) any other services set forth in 15 |
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418 | 418 | | an administrative services agreement or 16 |
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419 | 419 | | similar agreement or specified by the Sec-17 |
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420 | 420 | | retary through guidance or rulemaking.’’. 18 |
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421 | 421 | | (d) P |
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422 | 422 | | RIVACYREQUIREMENTS.—Section 408(b)(2) of 19 |
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423 | 423 | | the Employee Retirement Income Security Act of 1974 20 |
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424 | 424 | | (29 U.S.C. 1108(b)(2)), as amended by subsection (c), is 21 |
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425 | 425 | | further amended by adding at the end the following: 22 |
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426 | 426 | | ‘‘(C) P |
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427 | 427 | | RIVACY REQUIREMENTS .—Covered serv-23 |
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428 | 428 | | ice providers shall provide information under sub-24 |
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429 | 429 | | paragraph (B) in a manner consistent with the pri-25 |
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431 | 431 | | ssavage on LAPJG3WLY3PROD with BILLS 16 |
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432 | 432 | | •HR 2041 IH |
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433 | 433 | | vacy regulations promulgated under section 1 |
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434 | 434 | | 13402(a) of the Health Information Technology for 2 |
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435 | 435 | | Clinical Health Act (42 U.S.C. 17932(a)), and con-3 |
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436 | 436 | | sistent with the privacy regulations promulgated 4 |
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437 | 437 | | under the Health Insurance Portability and Ac-5 |
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438 | 438 | | countability Act of 1996 in part 160 and subparts 6 |
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439 | 439 | | A and E of part 164 of title 45, Code of Federal 7 |
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440 | 440 | | Regulations (or successor regulations) and shall re-8 |
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441 | 441 | | strict the use and disclosure of such information ac-9 |
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442 | 442 | | cording to such privacy, security, and breach notifi-10 |
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443 | 443 | | cation regulations and such privacy regulations. 11 |
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444 | 444 | | ‘‘(D) D |
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445 | 445 | | ISCLOSURE AND REDISCLOSURE .— 12 |
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446 | 446 | | ‘‘(i) L |
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447 | 447 | | IMITATION TO BUSINESS ASSOCI -13 |
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448 | 448 | | ATES.—A responsible plan fiduciary receiving 14 |
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449 | 449 | | information disclosed under subparagraph (B) 15 |
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450 | 450 | | may disclose such information only to the entity 16 |
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451 | 451 | | from which the information was received, the 17 |
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452 | 452 | | group health plan to which the information per-18 |
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453 | 453 | | tains, or to that entity’s business associates as 19 |
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454 | 454 | | defined in section 160.103 of title 45, Code of 20 |
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455 | 455 | | Federal Regulations (or successor regulations) 21 |
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456 | 456 | | or as permitted by the HIPAA Privacy Rule 22 |
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457 | 457 | | (parts 160 and 164, subparts A and E of title 23 |
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458 | 458 | | 45, Code of Federal Regulations). 24 |
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461 | 461 | | •HR 2041 IH |
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462 | 462 | | ‘‘(ii) CLARIFICATION REGARDING PUBLIC 1 |
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463 | 463 | | DISCLOSURE OF INFORMATION .—Nothing in 2 |
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464 | 464 | | this section shall prevent a group health plan or 3 |
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465 | 465 | | health insurance issuer offering group health 4 |
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466 | 466 | | insurance coverage, or a covered service pro-5 |
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467 | 467 | | vider, from placing reasonable restrictions on 6 |
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468 | 468 | | the public disclosure of the information de-7 |
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469 | 469 | | scribed in this subparagraph, except that such 8 |
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470 | 470 | | plan, issuer, or entity may not restrict disclo-9 |
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471 | 471 | | sure of such information to the Department of 10 |
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472 | 472 | | Labor. 11 |
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473 | 473 | | ‘‘(E) A |
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474 | 474 | | DDITIONAL PRIVACY REQUIREMENTS .— 12 |
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475 | 475 | | ‘‘(i) I |
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476 | 476 | | N GENERAL.—Covered service pro-13 |
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477 | 477 | | viders shall ensure that information provided 14 |
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478 | 478 | | under subparagraph (B) contains only summary 15 |
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479 | 479 | | health information, as defined in section 16 |
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480 | 480 | | 164.504(a) of title 45, Code of Federal Regula-17 |
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481 | 481 | | tions (or successor regulations). 18 |
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482 | 482 | | ‘‘(ii) R |
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483 | 483 | | ESTRICTIONS.—A group health plan 19 |
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484 | 484 | | shall comply with section 164.504(f) of title 45, 20 |
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485 | 485 | | Code of Federal Regulations (or successor regu-21 |
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486 | 486 | | lations) with respect to any information re-22 |
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487 | 487 | | ceived by the plan or disclosed to a plan spon-23 |
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488 | 488 | | sor or any other entity pursuant to this section, 24 |
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489 | 489 | | and a responsible plan administrator who is a 25 |
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492 | 492 | | •HR 2041 IH |
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493 | 493 | | plan sponsor shall act in accordance with the 1 |
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494 | 494 | | terms of the agreement described in such sec-2 |
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495 | 495 | | tion. 3 |
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496 | 496 | | ‘‘(F) R |
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497 | 497 | | ULE OF CONSTRUCTION .—Nothing in 4 |
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498 | 498 | | this section shall be construed to modify the require-5 |
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499 | 499 | | ments for the creation, receipt, maintenance, or 6 |
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500 | 500 | | transmission of protected health information under 7 |
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501 | 501 | | the privacy regulations promulgated under the 8 |
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502 | 502 | | Health Insurance Portability and Accountability Act 9 |
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503 | 503 | | of 1996 in part 160 and subparts A and E of part 10 |
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504 | 504 | | 164 of title 45, Code of Federal Regulations (or suc-11 |
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505 | 505 | | cessor regulations).’’. 12 |
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506 | 506 | | (e) R |
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507 | 507 | | ULE OF CONSTRUCTION.—Nothing in the 13 |
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508 | 508 | | amendments made by this section shall be construed to 14 |
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509 | 509 | | imply that a practice in relation to which a covered service 15 |
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510 | 510 | | provider is required to provide information as a result of 16 |
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511 | 511 | | such amendments is permissible under Federal law. 17 |
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512 | 512 | | (f) E |
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513 | 513 | | FFECTIVEDATE.—The amendments made by 18 |
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514 | 514 | | this subsection shall not apply to any contract or arrange-19 |
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515 | 515 | | ment entered into prior to January 1, 2026. Such amend-20 |
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516 | 516 | | ments shall apply to any contract or arrangement entered 21 |
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517 | 517 | | into on or after to such date, including any extension or 22 |
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518 | 518 | | renewal of a contract or arrangement, regardless of the 23 |
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519 | 519 | | date on which the original contract or agreement (or any 24 |
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520 | 520 | | previous extension or renewal) was entered into. 25 |
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523 | 523 | | •HR 2041 IH |
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524 | 524 | | SEC. 4. IMPLEMENTATION. 1 |
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525 | 525 | | Not later than 1 year after the date of enactment 2 |
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526 | 526 | | of this Act, the Secretary of Labor shall issue notice and 3 |
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527 | 527 | | comment rulemaking as necessary to implement the provi-4 |
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528 | 528 | | sions of this Act. The Secretary shall ensure that such 5 |
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529 | 529 | | rulemaking— 6 |
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530 | 530 | | (1) accounts for the varied compensation prac-7 |
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531 | 531 | | tices of covered service providers (as defined under 8 |
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532 | 532 | | section 408(b)(2)(B); and 9 |
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533 | 533 | | (2) establishes standards for the disclosure of 10 |
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534 | 534 | | expected compensation by such covered service pro-11 |
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535 | 535 | | viders. 12 |
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536 | 536 | | Æ |
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