Relating to certain cost controls for health care services

This bill relates to certain cost controls for health care services and may be cited as “The Patient’s Right to Save Act”. Under the bill, all health care providers (providers) are required to disclose the discounted cash price (cash price) the provider will accept for each specific health care service (service) for which the provider will accept cash payment. “Discounted cash price” is defined in the bill as the price an individual pays for a specific service if the individual pays with cash or a cash equivalent. The cash price shall be available to all covered persons (persons) and to all uninsured individuals. 180. A provider shall review each discounted cash price at least annually. Prior to the provision of a scheduled service that has a discounted cash price, persons and uninsured individuals shall be informed of their right to pay for the service via the cash price, and that a discounted cash price may not be less expensive than a rate negotiated by a health carrier (carrier), and that a person may compare the rates by contacting the carrier. A provider may grant a discounted cash price for a service when payment is promptly made. A provider shall not permit a carrier to recover a past payment based on a price difference. A provider shall not enter into a contract that prevents the provider from offering a cash price below the contracted rates the provider has with a carrier, or that prevents the provider from disclosing the provider’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 pharmacist via an easily accessible and secure internet site hosted by the carrier at the point the pharmacist fills a prescription drug to the person. A provider shall provide an individual with an itemized list of all services provided to the individual, a statement that the individual paid out-of-pocket for the services, and if the individual is a covered person, a statement that the provider will not make a claim against the person’s carrier for payment for the services provided, and a statement that the person may contact their plan regarding deductible credit. Each plan shall disclose to the plan’s covered persons the average allowed amount for each service that is covered under the person’s plan. If a plan fails to disclose each average allowed amount, a person may substitute a benchmark selected by the commissioner of insurance (commissioner). A person who elects to receive service at a cash price that is below the average allowed amount shall receive credit toward the person’s cost-sharing as if the service had been provided by a network provider. “Average allowed amount” is defined in the bill. 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 pay cash price for a generic-brand drug that results in a lower cost than the average allowed amount for the name-brand drug under the person’s plan, the plan shall apply any payments made by the person for the generic-brand 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. 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 discounted cash price and to receive a deductible credit. If a person pays a discounted cash price that is above the average allowed amount, 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 proof of payment submitted by a person pursuant to the bill, 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 proof of payment pursuant to Code chapter 514J. A person shall have access to a program that rewards the person with a savings incentive for medically necessary services received from providers that offer a cash price below the average allowed amount. Annually at enrollment or renewal, a carrier shall provide notice to persons via the carrier’s internet site of the savings incentive program and how the savings incentive program works. If a person exceeds the person’s annual deductible, the person’s plan shall notify the person of the savings incentive program. A person’s savings incentives for a service shall be calculated as the difference between the cash price and the average allowed amount. A savings incentive shall be divided equally between the person and the person’s plan, and may include a cash payment to the person and a third party as described in 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 carrier, for a service provided to the person, to require a provider to refund any payment made to the provider for a service provided to the person, or to require a provider to order or provide medically unnecessary services. 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. Applicability of the bill is detailed in the bill. The bill directs the department of administrative services (DAS) to conduct an analysis of the cost-effectiveness of offering a savings incentive program and deductible credit for state employees and retirees. DAS shall submit a report to the general assembly on or before September 1, 2026, containing an explanation as to the decisions to implement, or not to implement, a savings incentive program and deductible credit program. Any savings incentive program or deductible credit program found to be cost-effective shall be implemented for the 2027 state employee health insurance open enrollment period.