42 U.S.C. § 300gg–119 — Increasing transparency by removing gag clauses on price and quality information

submitted 82 years ago by Pub. L. 116-260 to r/title-42-THE-PUBLIC-HEALTH-AND-WELFARE · 668 words · no verdicts yet

in plain englishAI-generated · not legal advice

This law bans "gag clauses" that stop health plans from sharing cost and quality data with employers, members, and referring doctors. Plans can't be contractually blocked from getting or sharing de-identified claims data, as long as they follow privacy laws. Plans must certify each year that they comply.

(a) Increasing price and quality transparency for plan sponsors and group and individual market consumers A group health plan or issuer of group coverage can't sign a contract — with a provider, a network or association of providers, a third-party administrator, or any other service provider offering network access — that would restrict the plan or issuer from: sharing provider-specific cost or quality information with referring providers, the plan sponsor, or members and eligible individuals; electronically accessing de-identified claims and encounter data for each member on request, consistent with HIPAA, GINA, and ADA privacy rules, including per-claim financial information (like allowed amounts), provider name and specialty, service codes, and any other data element in the claim; or sharing that same data, or directing it be shared, with a "business associate" as HIPAA defines the term, consistent with those same privacy rules. An issuer of individual coverage faces a parallel rule: it can't be contractually blocked from sharing provider-specific price or quality information with referring providers or members, or from sharing that data with a business associate for plan design, administration, and quality-improvement purposes. None of this stops a provider, network, or service provider from placing reasonable limits on public disclosure of that same information. Each plan or issuer must certify to the Secretary every year that it complies with this subsection. And nothing here changes existing privacy protections under state and federal law, or otherwise limits a plan sponsor's or issuer's data access that HIPAA, GINA, and ADA privacy rules already allow.

the actual law source: uscode.house.gov ↗public domain

(a)1 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.].

Source credit: (July 1, 1944, ch. 373, title XXVII, § 2799A–9, as added Pub. L. 116–260, div. BB, title II, § 201(a), Dec. 27, 2020, 134 Stat. 2890.)

history & why it existsrecord from the source credit

1944Enacted · Pub. L. 116-260 · 134 Stat. 2890

A history note hasn’t been published yet. The record shows enactment by Pub. L. 116-260 on 1944-07-01.

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