HealthCare Roundtable e-News – July 17, 2023


Top News

House Committee on Education & the Workforce Advances New Legislation Focused on Increasing Transparency in Health Care

The House Committee on Education & the Workforce held a markup on a bipartisan health care package of four bills focused on transparency in health care, including for hospitals and pharmacy benefit managers (PBMs). Healthsperien’s detailed notes on the markup can be found here. The legislation discussed throughout the markup acts as a bipartisan attempt from lawmakers on the committee to rein in health care costs for consumers by increasing transparency. The role of PBMs and third party administrators (TPAs) in the health care marketplace remained a focal point throughout the hearing with multiple bills addressing gaps in previous legislation pertaining to transparency for third-party consultants. Transparency regarding billing practices for hospitals was also highlighted in the new legislative package with several members touching on the need for more clarity regarding the location and types of services provided to patients. The committee passed the following during today’s markup:

  • H.R. 4509, the Transparency in Billing Act, as amended, by a vote of 39-0. The bill would mandate that insurers only pay for claims from hospitals that have accurate billing practices. Specifically, the bill would require hospitals to correctly indicate through billing codes where a service for patients took place and what the service was. This means the hospitals would have to submit a unique health identifier for the department where the care is provided. Better Solutions for Healthcare, a coalition in which the Roundtable participates, supported the advancement of this legislation with a letter of support.
  • H.R. 4507, the Transparency in Coverage Act, as amended, by a vote of 38-1. The bill would promote transparency in health coverage and reform PBM services with respect to group health plans and other services. Specifically, the bill requires group health plans and issuers to make detailed information regarding in-network rates, allowed amounts of out-of-network services, volume restrictions, and medical management requirements available to the public. It also requires group health plans and issuers to establish an online self-service tool that allows the real-time provision of information directly to consumers.
  • H.R. 4527, the Health Data Act, as amended, by a vote of 38-1. The bill would ensure plan fiduciaries may access deidentified information relating to health claims and other purposes. The act would look to strengthen the gag clause section of the No Surprises Act by eliminating limitations on the number of claims an employer can audit and restrictions on the number of audits that employers can conduct as well as a variety of other measures that would increase transparency.
  • H.R. 4508, the Hidden Fee Disclosure Act, as amended, by a vote of 38-1. The bill would strengthen the application of certain employer-sponsored health plan disclosure requirements by requiring PBMs to comply with existing rules. The act would clarify the role of PBMs and TPAs in the health care market by classifying them as consultants. This would close many compliance loopholes and ensure PBMs and TPAs are in compliance with disclosure requirements from previous legislation like the No Surprises Act.


Senate Finance Committee Leaders Release PBM Reform Discussion Draft

The Senate Finance Committee released a discussion draft for a bill that would establish pharmacy benefit manager (PBM) reporting requirements with respect to prescription drug plans and MA-PD plans under Medicare Part D. The bill, called the Medicare PBM Accountability Act, was introduced by Senator Cortez Masto (D-NV) alongside Senator Tillis (R-NC), Senator Wyden (D-OR), and Senator Crapo (R-ID). The Medicare PBM Accountability Act’s provisions would require PBMs to report a range of information to prescription drug plan (PDP) sponsors and to the Secretary upon request. PBMs would be required to detail information including which drugs were dispensed, average costs and prices, out-of-pocket spending by plan enrollees, direct or indirect remuneration on drugs, and names of PBM affiliates, along with other information. The bill would also require PBMs to be more transparent about their guarantees and cost performance evaluation. This draft discussion comes a month after Senate Finance Committee leaders introduced the Patients Before Middlemen (PBM) Act, a bill that would decouple PBM compensation from drug prices. Senate Finance Committee leaders also released a legislative framework in April addressing PBMs and the prescription drug supply chain.

Administrative Action

The Centers for Disease Control and Prevention (CDC) announced they will launch the Bridge Access Program for COVID-19 Vaccines this fall. The Bridge Access Program will temporarily provide uninsured and underinsured adults with free COVID-19 vaccinations. CDC is working with state and local immunization programs to help distribute the vaccines to community-based providers. In addition, CDC will collaborate with large, national pharmacy chains to further ensure uninsured adults receive free COVID-19 vaccines. CDC is expecting to reimburse the pharmacies for the administration fees. The Bridge Access Program will end in December 2024. In addition to CDC’s actions regarding access to COVID-19 vaccines, the Centers for Medicare and Medicaid (CMS) and Department of Health and Human Services (HHS) have highlighted the importance of accessible COVID-19 vaccines especially during a transition to traditional pathways for procurement, distribution, and payment.

Congressional Action

  • Senate Majority Leader Chuck Schumer (D-NY) issued a letter to his Senate colleagues on Sunday evening outlining key areas that will be of focus throughout the next work period. Senator Schumer expressed the need to move forward and work with Republicans on a number of health care-related policy efforts including advancing bills that would lower the cost of insulin and prescription drugs. The letter also touched on the reauthorization of the Farm Bill and emphasized the need to “promote community health.” Notably, Congress must reauthorize the Community Health Center Fund, which represents about 70 percent of the federal funding for community health centers, by September 30.
  • Health, Education, Labor, and Pensions (HELP) Ranking Member Cassidy (R-LA) introduced a bill titled, the Community Health Care Reauthorization Act, which would extend funding for teaching health centers that operate graduate medical education (GME) programs, community health centelrs, and the National Health Service Corps. Cassidy’s bill differs from Chairman Sanders’ (I-VT) reauthorization plan by providing smaller increases in funding (e.g., a $400 million increase for community health centers over two years compared to $130 billion for community health centers and $60 billion in funding to help grow the workforce over five years, respectively). The programs’ funding will expire at the end of September which worries advocates given the partisan divide. Despite this, Cassidy notes that his bill reflects recent bipartisan legislation passed out of committee in the House.

Regulatory Action

  • On Tuesday, the Department of Health and Human Services (HHS) through the Office of Civil Rights (OCR) announced a Notice of Proposed Rulemaking (NPRM) to affirm civil rights and equal opportunity for people nationwide in HHS funded programs and services. The proposed rule, known as the Health and Human Services Grants Regulation (HHS Grants Rule), would protect LGBTQI+ people from discrimination in important health and human services. The proposed HHS Grants Rule, if finalized, would clarify and reaffirm the prohibition on discrimination on the basis of sexual orientation and gender identity in federal statutes administered by HHS, consistent with the Supreme Court’s decision in Bostock v. Clayton County. In addition, this NPRM builds on President Biden’s Executive Orders on Preventing and Combating Discrimination on the Basis of Gender Identity and Sexual Orientation and Advancing Equality for Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Individuals.
  • The U.S. Food and Drug Administration (FDA) granted approval of Opill(norgestrel) tablet for nonprescription use to prevent pregnancy, making it the first daily oral contraceptive approved for use in the U.S. without a prescription. Norgestrel was first approved as safe and effective to be prescribed in 1973 but to be approved for over-the-counter use HRA Pharma had to show that it could be used safely and effectively by consumers relying solely on the nonprescription drug labeling. Over-the-counter approval of Norgestrel is set to reduce barriers to access of oral contraception for individuals with limited access to a health care provider and reduce the number of unintended pregnancies in the U.S. Although contraceptive coverage without a copay is required by the Affordable Care Act, it remains unclear whether that applies to over-the-counter options, and while over-the-counter medications are typically cheaper than prescription drugs, they are not usually covered by insurance therefore the price of Opill, which has yet to be disclosed, will also determine its accessibility.
  • The Centers for Medicare and Medicaid Services released (fact sheet here) their calendar year (CY) 2024 Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) Proposed Rule. CMS notes that this proposed rule is one of several proposed rules that reflect a broader Administration-wide strategy to create a more equitable health care system that results in better access to care, quality, affordability, and innovation. Notably, overall payment rates under the MPFS are proposed to be reduced by 1.25% in CY 2024 compared to CY 2023. CMS is also proposing significant increases in payment for primary care and other kinds of direct patient care. The proposed CY 2024 MPFS conversion factor is $32.75, a decrease of $1.14 (or 3.34%) from the current CY 2023 conversion factor of $33.89. Comments are due by September 11, 2023, and can be submitted here.


  • The Centers for Medicare and Medicaid Services’ (CMS) Center for Medicare and Medicaid Innovation (CMMI) released a retrospective analysis of model evaluations to determine the reach of Innovation Center models and assess the degree of and impact of health equity incorporation in model designs and evaluations. Under CMMI’s 2021 strategic refresh, the Innovation Center has sought to embed health equity in every aspect of its models and increase the focus on understanding populations. Notably, the analysis found the variable quality of race/ethnicity data in Medicare and Medicaid claims data presents a challenge for understanding whether models reach and enroll underserved beneficiaries. In addition, model designs have not always considered needs specific to underserved beneficiaries and have not prioritized closing gaps in care. Lastly, model designs that do not prioritize enrolling substantial numbers of underserved beneficiaries result in small sample sizes and limit the ability to draw conclusions from analyses related to equity.
  • The Centers for Medicare and Medicaid Services (CMS) released the Calendar Year (CY) 2024 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed Rule, which determines Medicare payment rates for hospital outpatient and ASC services. Comments are due September 11, 2023. Of note, the proposed rule updates OPPS payment rates for CY 2024 for hospitals meeting quality reporting requirements by 2.8%, and ASC rates also by 2.8%. With regards to behavioral health, the rule includes proposals to implement provisions of the Consolidated Appropriations Act, 2023 that created a new benefit category for Intensive Outpatient Program services and it strengthens hospital price transparency regulations.


The Centers for Medicare & Medicaid Services (CMS) posted an expanded report to Congress for Non-Emergency Medical Transportation (NEMT) in Medicaid. The report includes Transformed Medicaid Statistical Information System (T-MSIS) data from 2018-2021, an additional year from the previous report. The new report includes analysis on Medicaid’s coverage of NEMT, including information on the types of medical services accessed when using NEMT, by beneficiary subgroup, monthly trends in the use of NEMT versus telehealth services, and a comparison by delivery model of the volume of NEMT services used by states. The U.S. Department of Health and Human Services (HHS), through the CMS, is statutorily required to conduct an analysis on the nationwide T-MSIS data set and identify recommendations relating to Medicaid coverage of NEMT for medically necessary services to Congress.