Relating to certain cost controls for health care services, and including penalties

A health carrier (carrier) shall post the cash prices via an easily accessible and secure internet site, update any change in a cash price within five days of the change, and review each cash price at least annually. During the appointment scheduling process, and any intake process prior to the provision of a service, persons and uninsured individuals shall be informed of their right to pay for the service via the cash price. A person shall also be advised that they qualify for a deductible credit if they have not exceeded their deductible to date, and the criteria in the bill is satisfied. A carrier shall not enter into a contract that prevents the carrier from offering a cash price below the contracted rates the carrier has with other commercial or public payors, or that prevents the carrier from disclosing the carrier’s cash price to persons. A person’s out-of-pocket pricing for each drug on a carrier’s formulary shall be available to a provider via an easily accessible and secure internet site hosted by the carrier at the point the provider prescribes drugs to a person. Each plan shall disclose to the plan’s covered persons the negotiated charge for each service that is covered under the person’s plan. If a plan fails to disclose each negotiated charge, a person may substitute a benchmark selected by the commissioner of insurance (commissioner) for the negotiated charge. A person who elects to receive service at a cash price that is below the deidentified minimum negotiated charge (negotiated charge) shall receive credit toward the person’s cost-sharing as if the service had been provided by a network provider. “Deidentified minimum negotiated charge” is defined in the bill as the lowest cost for a specific service that a provider has negotiated with a carrier for a person’s plan. A plan shall not discriminate in the form of payment for any in-network covered service solely on the basis that the person was referred for the service by an out-of-network provider. If a person elects to use a pharmacy discount program, a drug manufacturer’s rebate, or other discount or rebate program that results in a lower cost for a drug than if the person uses the person’s plan, the plan shall apply any payments made by the person for the drug as detailed in the bill. A plan is required to provide an online form for the purpose of a person submitting proof of payment, and to annually inform persons of their options related to discounts and rebates. Annually at enrollment or renewal, a carrier shall provide notice to persons via the carrier’s health plan materials and on the carrier’s internet site of the option and the process to receive a covered service at a cash price below the negotiated charge. If a person pays a cash price that is above the negotiated charge, the plan shall give the person credit toward the person’s cost-sharing in an amount equal to the cash price. If a carrier denies a claim submitted by a person, the carrier shall notify the commissioner and provide evidence to support the denial to the person and the commissioner. A person may appeal a denial of a claim to the commissioner as detailed in the bill. If the commissioner determines that the carrier improperly denied the person’s claim, the carrier shall pay the person’s costs and attorney fees, accept the person’s claim, and provide cash compensation to the person as detailed in the bill. If a carrier denies or more claims in any one quarter, the commissioner shall have the authority to investigate the denials.6. If, after hearing, the commissioner determines that a person has engaged in an unfair or deceptive act or practice, the commissioner shall reduce the findings to writing and shall issue and cause to be served upon the person charged with the violation a copy of such findings, an order requiring such person to cease and desist from engaging in such act or practice, and may at the commissioner’s discretion order any one or more penalties, license suspension, or license revocation as detailed in the bill. For costs that exceed a person’s deductible, the person shall have access to a program that directly rewards the person with a savings incentive as detailed in the bill. A provider shall not initiate or pursue a collection action (action) against a person, or a person’s guarantor, for a debt owed for a service unless the provider is in material compliance with the bill on the date that the service is provided to the person. If a provider initiates or pursues an action, the person may file for a declaratory judgment with a court of competent jurisdiction and the provider shall not continue the collection action while the suit is pending. If the court finds in favor of the person, the court shall order the provider to comply with the requirements detailed in the bill. Provided the provider does not initiate or pursue an action in violation of the bill, the bill shall not be construed to prohibit a provider from billing a person, a person’s guarantor, or a third-party payor, including a health insurer, for a service provided to the person, or to require a provider to refund any payment made to the provider for a service provided to a person. If a provision of the bill or its application to any person or circumstance is held invalid, the invalidity does not affect other provisions or applications of the bill which can be given effect without the invalid provision or application.