Bill Text: IA SF2381 | 2023-2024 | 90th General Assembly | Amended

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Bill Title: A bill for an act relating to certain cost controls for health care services. (Formerly SF 431.)

Spectrum: Committee Bill

Status: (Engrossed - Dead) 2024-03-07 - Subcommittee recommends indefinite postponement. Vote Total: 2-0. [SF2381 Detail]

Download: Iowa-2023-SF2381-Amended.html

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Senate File 2381 - Reprinted
SENATE FILE 2381
BY COMMITTEE ON HEALTH AND
HUMAN SERVICES
(SUCCESSOR TO SF 431)
(As Amended and Passed by the Senate March 4, 2024 )
A BILL FOR
An Act relating to certain cost controls for health care
services.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
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Section 1. Section 507B.4, subsection 3, Code 2024, is
amended by adding the following new paragraph:
NEW PARAGRAPH . v. Improper denial of claims. A health
carrier improperly denying claims under chapter 514M.
Sec. 2. NEW SECTION . 514M.1 Short title.
This chapter shall be known and may be cited as “The
Patient’s Right to Save Act” .
Sec. 3. NEW SECTION . 514M.2 Definitions.
As used in this chapter, unless the context otherwise
requires:
1. “Average allowed amount” means the average of all
contractually agreed upon amounts paid by a health benefit
plan or a health carrier to a health care provider or other
entity participating in the health carrier’s network. The
average shall be calculated according to payments within a
reasonable amount of time not to exceed one calendar year. The
commissioner may approve methodologies for calculating the
average allowed amount that are based on any of the following:
a. A specific covered person’s health plan.
b. All health plans offered in the state by a specific
health carrier.
c. Geographic area.
2. “Cost-sharing” means any coverage limit, copayment,
coinsurance, deductible, or other out-of-pocket expense
obligation imposed on a covered person by a policy, contract,
or plan providing for third-party payment or prepayment of
health or medical expenses.
3. “Covered benefits” or “benefits” means health care
services that a covered person is entitled to under the terms
of a health benefit plan.
4. “Covered person” means a policyholder, subscriber,
enrollee, or other individual participating in a health benefit
plan.
5. “Discounted cash price” means the price an individual
pays for a specific health care service if the individual pays
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for the health care service with cash or a cash equivalent.
6. “Health benefit plan” means a policy, contract,
certificate, or agreement offered or issued by a health carrier
to provide, deliver, arrange for, pay for, or reimburse any of
the costs of health care services.
7. “Health care provider” means a physician or other
health care practitioner licensed, accredited, registered, or
certified to perform specified health care services consistent
with state law, an institution providing health care services,
a health care setting, including but not limited to a hospital
or other licensed inpatient center, an ambulatory surgical
or treatment center, a skilled nursing center, a residential
treatment center, a diagnostic, laboratory, and imaging center,
or a rehabilitation or other therapeutic health setting.
8. “Health care services” means services for the diagnosis,
prevention, treatment, cure, or relief of a health condition,
illness, injury, or disease.
9. a. “Health carrier” means an entity subject to the
insurance laws and regulations of this state, or subject
to the jurisdiction of the commissioner, including an
insurance company offering sickness and accident plans, a
health maintenance organization, a nonprofit health service
corporation, a plan established pursuant to chapter 509A
for public employees, or any other entity providing a plan
of health insurance, health care benefits, or health care
services.
b. For purposes of this chapter, “health carrier” does not
include an entity providing any of the following:
(1) Coverage for accident-only, or disability income
insurance.
(2) Coverage issued as a supplement to liability insurance.
(3) Liability insurance, including general liability
insurance and automobile liability insurance.
(4) Workers’ compensation or similar insurance.
(5) Automobile medical-payment insurance.
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(6) Credit-only insurance.
(7) Coverage for on-site medical clinic care.
(8) Other similar insurance coverage, specified in
federal regulations, under which benefits for medical care
are secondary or incidental to other insurance coverage or
benefits.
c. For purposes of this chapter, “health carrier” does not
include an entity providing benefits under a separate policy
including any of the following:
(1) Limited scope dental or vision benefits.
(2) Benefits for long-term care, nursing home care, home
health care, or community-based care.
(3) Any other similar limited benefits as provided by the
commissioner by rule.
d. For purposes of this chapter, “health carrier” does not
include an entity providing benefits offered as independent
noncoordinated benefits including any of the following:
(1) Coverage only for a specified disease or illness.
(2) A hospital indemnity or other fixed indemnity
insurance.
e. For purposes of this chapter, “health carrier” does
not include an entity providing a Medicare supplemental
health insurance policy as defined under section 1882(g)(1)
of the federal Social Security Act, coverage supplemental to
the coverage provided under 10 U.S.C. ch. 55, and similar
supplemental coverage provided to coverage under group health
insurance coverage.
10. “Pharmacist” means the same as defined in section
155A.3.
11. “Pharmacy” means the same as defined in section 155A.3.
Sec. 4. NEW SECTION . 514M.3 Health care services —— cost
controls.
1. a. All health care providers shall establish and
disclose the discounted cash price the health care provider
will accept for specific health care services. The disclosure
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shall specify if the discounted cash price varies due to
different circumstances, including but not limited to the
day or time a health care service is provided, the office or
location at which the health care service is provided, how
quickly an individual pays the discounted cash price for a
health care service the individual received, the income level
of the individual who received the health care service, or
the ancillary services or amenities provided to an individual
at the same time the health care service is provided. The
discounted cash price shall be available to all covered persons
and to all uninsured individuals. A health care provider may
satisfy the requirements of this paragraph by complying with
the centers for Medicare and Medicaid services of the United
States department of health and human services hospital price
transparency final rule published in the federal register on
November 22, 2023.
b. A health care provider shall post all discounted cash
prices on the health care provider’s internet site in a
manner that is easily accessible to the public. A health care
provider shall update any change in a discounted cash price
within ten calendar days of the change, and shall review each
discounted cash price at least annually.
c. (1) Prior to the provision of a scheduled health care
service, a health care provider shall inform all covered
persons and uninsured individuals of the right of the covered
person or uninsured individual to pay for a health care service
via the discounted cash price. The notice may be provided
electronically, verbally, in writing, or posted at the physical
location of the health care provider.
(2) Prior to the provision of a scheduled health care
service, a health care provider shall inform a covered person
that the covered person may qualify for a deductible credit
if the covered person pays the discounted cash price for the
health care service and if the discounted cash price is below
the average allowed amount paid by the health carrier to
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network providers for a comparable health care service. The
notice may be provided electronically, verbally, in writing, or
posted at the physical location of the health care provider.
d. A health care provider shall not enter into a contract
that prohibits the health care provider from offering a
discounted cash price below the contracted rates the health
care provider has with a health carrier, or that prohibits the
health care provider from disclosing the health care provider’s
discounted cash price under paragraph “b” .
e. A health carrier shall not enter into a contract with a
health care provider that prohibits the health care provider
from offering a discounted cash price below the contracted
rates the health care provider has with a health carrier, or
that prohibits the health care provider from disclosing the
health care provider’s discounted cash price under paragraph
“b” .
f. A covered person’s out-of-pocket pricing for each
prescription drug on a health carrier’s formulary shall be
available to a pharmacist via an easily accessible and secure
internet site hosted by the health carrier at the point the
pharmacist fills a prescription drug to the covered person.
g. A health care provider shall provide an individual with
an itemized list of all health care services provided to the
individual, a statement that the individual paid out-of-pocket
for the health care services, and a statement that the health
care provider will not make a claim against a health carrier
for payment for the health care services provided to the
individual if the individual is a covered person.
2. Each health benefit plan shall disclose to the health
benefit plan’s covered persons the average allowed amount for
each health care service that is covered under the covered
person’s health benefit plan. If a health benefit plan fails
to disclose the average allowed amount for a health care
service, a covered person may substitute a benchmark selected
by the commissioner.
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3. A covered person who elects to receive a covered health
care service at a discounted cash price that is below the
average allowed amount shall receive credit toward the covered
person’s in-network cost-sharing as specified in the covered
person’s health benefit plan, as if the health care service is
provided by an in-network health care provider.
4. A health benefit plan shall not discriminate in the
form of payment for any covered in-network health care service
solely on the basis that the covered person was referred for
the health care service by an out-of-network health care
provider.
5. a. If a covered person elects to pay cash price for
a generic-brand covered prescription drug that results in a
lower cost than the average allowed amount for the name-brand
covered prescription drug under the covered person’s health
benefit plan, excluding any drug manufacturer’s rebate or
other discount from the average allowed amount, the health
benefit plan shall apply any payments made by the covered
person for the generic-brand covered prescription drug
to the covered person’s cost-sharing as specified in the
covered person’s health benefit plan as if the covered person
purchased the generic-brand prescription drug from a network
pharmacy using the covered person’s health benefit plan. The
health benefit plan shall credit half the difference in the
cash price for the generic-brand covered prescription drug
and the average allowed amount for the name-brand covered
prescription drug, excluding any drug manufacturer’s rebate
or other discount from the average allowed amount, toward
the covered person’s cost-sharing for health care services
that are covered or that are considered formulary under the
covered person’s health benefit plan. The health benefit
plan may credit half the difference in the cash price for
the generic-brand covered prescription drug and the average
allowed amount for the name-brand covered prescription drug,
excluding any drug manufacturer’s rebate or other discount
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from the average allowed amount, toward the covered person’s
cost-sharing for health care services that are not covered
or that are considered nonformulary under the covered
person’s health benefit plan. This paragraph shall not be
construed to restrict a health benefit plan from requiring a
preauthorization or other precertification normally required by
the health benefit plan.
b. A health benefit plan shall provide a downloadable or
interactive online form for a covered person to submit proof of
payment under paragraph “a” , and shall annually inform covered
persons of their options under this subsection.
6. Annually at enrollment or renewal, a health carrier shall
provide notice to covered persons via the health carrier’s
health benefit plan materials and the health carrier’s internet
site of the option, and the process, to receive a covered
health care service at a discounted cash price.
7. If a covered person pays a discounted cash price that is
above the average allowed amount, the health benefit plan shall
credit the covered person’s cost-sharing an amount equal to
the lesser of the discounted cash price or the average allowed
amount.
8. a. If a health carrier denies a claim submitted by a
covered person pursuant to this chapter, the health carrier
shall notify the commissioner and provide evidence to support
the denial to the covered person and to the commissioner.
b. A covered person may appeal a claim denial pursuant to
chapter 514J.
9. a. A covered person shall have access to a program that
directly rewards the covered person with a savings incentive
for medically necessary covered health care services received
from health care providers that offer a discounted cash price
below the average allowed amount. Annually at enrollment or
renewal, a health carrier shall provide notice to covered
persons via the health carrier’s health benefit plan materials
and the health carrier’s internet site of the savings incentive
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program and how the savings incentive program works. If a
covered person exceeds the covered person’s annual deductible,
the covered person’s health benefit plan shall notify the
covered person of the savings incentive program and how the
savings incentive program works.
b. A covered person’s savings incentive for a specific
health care service shall be calculated as the difference
between the discounted cash price and the average allowed
amount. A savings incentive shall be divided equally between
the covered person and the covered person’s health benefit
plan, and may include a cash payment to the covered person. If
a third party helps facilitate a covered person in utilizing
a discounted cash price that saves money for the covered
person, the covered person may share a portion of their savings
incentive with the third party.
c. Savings incentives under this subsection shall not be
an administrative expense of the health benefit plan for rate
development or rate filing purposes.
10. This chapter shall not be construed to prohibit a health
care provider from billing a covered person, a covered person’s
guarantor, or a third-party payor including a health insurer,
for health care services provided to a covered person; or to
require a health care provider to refund any payment made to
the health care provider for a health care service provided to
a covered person.
11. If a provision of this chapter or its application to
any person or circumstance is held invalid, the invalidity does
not affect other provisions or applications of this chapter
which can be given effect without the invalid provision or
application.
Sec. 5. SAVINGS INCENTIVE PROGRAM AND DEDUCTIBLE CREDIT
PROGRAM FOR STATE EMPLOYEES.
1. Before August 1, 2025, the department of administrative
services shall conduct an analysis of the cost-effectiveness of
offering a savings incentive program and deductible credit for
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state employees and retirees.
2. On or before September 1, 2025, the department of
administrative services shall submit a report to the general
assembly that contains an explanation as to the decision to
implement, or not implement, a savings incentive program or
deductible credit program.
3. Any savings incentive program or deductible credit found
to be cost-effective shall be implemented for the 2026 state
employee health insurance open enrollment period.
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