Senate Amendment to House File 2488 H-8252 Amend House File 2488, as amended, passed, and reprinted by 1 the House, as follows: 2 1. Page 1, before line 1 by inserting: 3 < DIVISION I 4 PRIOR AUTHORIZATIONS AND EXEMPTIONS > 5 2. Page 3, after line 8 by inserting: 6 < DIVISION ___ 7 COST CONTROLS FOR HEALTH CARE SERVICES 8 Sec. ___. Section 507B.4, subsection 3, Code 2024, is 9 amended by adding the following new paragraph: 10 NEW PARAGRAPH . v. Improper denial of claims. A health 11 carrier improperly denying claims under chapter 514M. 12 Sec. ___. NEW SECTION . 514M.1 Short title. 13 This chapter shall be known and may be cited as “The 14 Patient’s Right to Save Act” . 15 Sec. ___. NEW SECTION . 514M.2 Definitions. 16 As used in this chapter, unless the context otherwise 17 requires: 18 1. “Average allowed amount” means the average of all 19 contractually agreed upon amounts paid by a health benefit 20 plan or a health carrier to a health care provider or other 21 entity participating in the health carrier’s network. The 22 average shall be calculated according to payments within a 23 reasonable amount of time not to exceed one calendar year. The 24 commissioner may approve methodologies for calculating the 25 average allowed amount that are based on any of the following: 26 a. A specific covered person’s health plan. 27 b. All health plans offered in the state by a specific 28 health carrier. 29 c. Geographic area. 30 2. “Cost-sharing” means any coverage limit, copayment, 31 coinsurance, deductible, or other out-of-pocket expense 32 obligation imposed on a covered person by a policy, contract, 33 or plan providing for third-party payment or prepayment of 34 health or medical expenses. 35 -1- HF 2488.3860.S (1) 90 1/ 9 #1. #2.

3. “Covered benefits” or “benefits” means health care 1 services that a covered person is entitled to under the terms 2 of a health benefit plan. 3 4. “Covered person” means a policyholder, subscriber, 4 enrollee, or other individual participating in a health benefit 5 plan. 6 5. “Discounted cash price” means the price an individual 7 pays for a specific health care service if the individual pays 8 for the health care service with cash or a cash equivalent. 9 6. “Health benefit plan” means a policy, contract, 10 certificate, or agreement offered or issued by a health carrier 11 to provide, deliver, arrange for, pay for, or reimburse any of 12 the costs of health care services. 13 7. “Health care provider” means a physician or other 14 health care practitioner licensed, accredited, registered, or 15 certified to perform specified health care services consistent 16 with state law, an institution providing health care services, 17 a health care setting, including but not limited to a hospital 18 or other licensed inpatient center, an ambulatory surgical 19 or treatment center, a skilled nursing center, a residential 20 treatment center, a diagnostic, laboratory, and imaging center, 21 or a rehabilitation or other therapeutic health setting. 22 8. “Health care services” means services for the diagnosis, 23 prevention, treatment, cure, or relief of a health condition, 24 illness, injury, or disease. 25 9. a. “Health carrier” means an entity subject to the 26 insurance laws and regulations of this state, or subject 27 to the jurisdiction of the commissioner, including an 28 insurance company offering sickness and accident plans, a 29 health maintenance organization, a nonprofit health service 30 corporation, a plan established pursuant to chapter 509A 31 for public employees, or any other entity providing a plan 32 of health insurance, health care benefits, or health care 33 services. 34 b. For purposes of this chapter, “health carrier” does not 35 -2- HF 2488.3860.S (1) 90 2/ 9

include an entity providing any of the following: 1 (1) Coverage for accident-only, or disability income 2 insurance. 3 (2) Coverage issued as a supplement to liability insurance. 4 (3) Liability insurance, including general liability 5 insurance and automobile liability insurance. 6 (4) Workers’ compensation or similar insurance. 7 (5) Automobile medical-payment insurance. 8 (6) Credit-only insurance. 9 (7) Coverage for on-site medical clinic care. 10 (8) Other similar insurance coverage, specified in 11 federal regulations, under which benefits for medical care 12 are secondary or incidental to other insurance coverage or 13 benefits. 14 c. For purposes of this chapter, “health carrier” does not 15 include an entity providing benefits under a separate policy 16 including any of the following: 17 (1) Limited scope dental or vision benefits. 18 (2) Benefits for long-term care, nursing home care, home 19 health care, or community-based care. 20 (3) Any other similar limited benefits as provided by the 21 commissioner by rule. 22 d. For purposes of this chapter, “health carrier” does not 23 include an entity providing benefits offered as independent 24 noncoordinated benefits including any of the following: 25 (1) Coverage only for a specified disease or illness. 26 (2) A hospital indemnity or other fixed indemnity 27 insurance. 28 e. For purposes of this chapter, “health carrier” does 29 not include an entity providing a Medicare supplemental 30 health insurance policy as defined under section 1882(g)(1) 31 of the federal Social Security Act, coverage supplemental to 32 the coverage provided under 10 U.S.C. ch. 55, and similar 33 supplemental coverage provided to coverage under group health 34 insurance coverage. 35 -3- HF 2488.3860.S (1) 90 3/ 9

10. “Pharmacist” means the same as defined in section 1 155A.3. 2 11. “Pharmacy” means the same as defined in section 155A.3. 3 Sec. ___. NEW SECTION . 514M.3 Health care services —— cost 4 controls. 5 1. a. All health care providers shall establish and 6 disclose the discounted cash price the health care provider 7 will accept for specific health care services. The disclosure 8 shall specify if the discounted cash price varies due to 9 different circumstances, including but not limited to the 10 day or time a health care service is provided, the office or 11 location at which the health care service is provided, how 12 quickly an individual pays the discounted cash price for a 13 health care service the individual received, the income level 14 of the individual who received the health care service, or 15 the ancillary services or amenities provided to an individual 16 at the same time the health care service is provided. The 17 discounted cash price shall be available to all covered persons 18 and to all uninsured individuals. A health care provider may 19 satisfy the requirements of this paragraph by complying with 20 the centers for Medicare and Medicaid services of the United 21 States department of health and human services hospital price 22 transparency final rule published in the federal register on 23 November 22, 2023, or any amendment thereto. 24 b. A health care provider shall post all discounted cash 25 prices on the health care provider’s internet site in a 26 manner that is easily accessible to the public. A health care 27 provider shall update any change in a discounted cash price 28 within ten calendar days of the change, and shall review each 29 discounted cash price at least annually. 30 c. (1) Prior to the provision of a scheduled health care 31 service, a health care provider shall inform all covered 32 persons and uninsured individuals of the right of the covered 33 person or uninsured individual to pay for a health care service 34 via the discounted cash price. The notice may be provided 35 -4- HF 2488.3860.S (1) 90 4/ 9

electronically, verbally, in writing, or posted at the physical 1 location of the health care provider. 2 (2) Prior to the provision of a scheduled health care 3 service, a health care provider shall inform a covered person 4 that the covered person may qualify for a deductible credit 5 if the covered person pays the discounted cash price for the 6 health care service and if the discounted cash price is below 7 the average allowed amount paid by the health carrier to 8 network providers for a comparable health care service. The 9 notice may be provided electronically, verbally, in writing, or 10 posted at the physical location of the health care provider. 11 d. A health care provider shall not enter into a contract 12 that prohibits the health care provider from offering a 13 discounted cash price below the contracted rates the health 14 care provider has with a health carrier, or that prohibits the 15 health care provider from disclosing the health care provider’s 16 discounted cash price under paragraph “b” . 17 e. A health carrier shall not enter into a contract with a 18 health care provider that prohibits the health care provider 19 from offering a discounted cash price below the contracted 20 rates the health care provider has with a health carrier, or 21 that prohibits the health care provider from disclosing the 22 health care provider’s discounted cash price under paragraph 23 “b” . 24 f. A covered person’s out-of-pocket pricing for each 25 prescription drug on a health carrier’s formulary shall be 26 available to a pharmacist via an easily accessible and secure 27 internet site hosted by the health carrier at the point the 28 pharmacist fills a prescription drug to the covered person. 29 g. A health care provider shall provide an individual with 30 an itemized list of all health care services provided to the 31 individual, a statement that the individual paid out-of-pocket 32 for the health care services, and a statement that the health 33 care provider will not make a claim against a health carrier 34 for payment for the health care services provided to the 35 -5- HF 2488.3860.S (1) 90 5/ 9

individual if the individual is a covered person. 1 2. Each health benefit plan shall disclose to the health 2 benefit plan’s covered persons the average allowed amount for 3 each health care service that is covered under the covered 4 person’s health benefit plan. If a health benefit plan fails 5 to disclose the average allowed amount for a health care 6 service, a covered person may substitute a benchmark selected 7 by the commissioner. 8 3. A covered person who elects to receive a covered health 9 care service at a discounted cash price that is below the 10 average allowed amount shall receive credit toward the covered 11 person’s in-network cost-sharing as specified in the covered 12 person’s health benefit plan, as if the health care service is 13 provided by an in-network health care provider. 14 4. A health benefit plan shall not discriminate in the 15 form of payment for any covered in-network health care service 16 solely on the basis that the covered person was referred for 17 the health care service by an out-of-network health care 18 provider. 19 5. a. If a covered person elects to pay cash price for 20 a generic-brand covered prescription drug that results in a 21 lower cost than the average allowed amount for the name-brand 22 covered prescription drug under the covered person’s health 23 benefit plan, excluding any drug manufacturer’s rebate or 24 other discount from the average allowed amount, the health 25 benefit plan shall apply any payments made by the covered 26 person for the generic-brand covered prescription drug 27 to the covered person’s cost-sharing as specified in the 28 covered person’s health benefit plan as if the covered person 29 purchased the generic-brand prescription drug from a network 30 pharmacy using the covered person’s health benefit plan. The 31 health benefit plan shall credit half the difference in the 32 cash price for the generic-brand covered prescription drug 33 and the average allowed amount for the name-brand covered 34 prescription drug, excluding any drug manufacturer’s rebate 35 -6- HF 2488.3860.S (1) 90 6/ 9

or other discount from the average allowed amount, toward 1 the covered person’s cost-sharing for health care services 2 that are covered or that are considered formulary under the 3 covered person’s health benefit plan. The health benefit 4 plan may credit half the difference in the cash price for 5 the generic-brand covered prescription drug and the average 6 allowed amount for the name-brand covered prescription drug, 7 excluding any drug manufacturer’s rebate or other discount 8 from the average allowed amount, toward the covered person’s 9 cost-sharing for health care services that are not covered 10 or that are considered nonformulary under the covered 11 person’s health benefit plan. This paragraph shall not be 12 construed to restrict a health benefit plan from requiring a 13 preauthorization or other precertification normally required by 14 the health benefit plan. 15 b. A health benefit plan shall provide a downloadable or 16 interactive online form for a covered person to submit proof of 17 payment under paragraph “a” , and shall annually inform covered 18 persons of their options under this subsection. 19 6. Annually at enrollment or renewal, a health carrier shall 20 provide notice to covered persons via the health carrier’s 21 health benefit plan materials and the health carrier’s internet 22 site of the option, and the process, to receive a covered 23 health care service at a discounted cash price. 24 7. If a covered person pays a discounted cash price that is 25 above the average allowed amount, the health benefit plan shall 26 credit the covered person’s cost-sharing an amount equal to 27 the lesser of the discounted cash price or the average allowed 28 amount. 29 8. a. If a health carrier denies a claim submitted by a 30 covered person pursuant to this chapter, the health carrier 31 shall notify the commissioner and provide evidence to support 32 the denial to the covered person and to the commissioner. 33 b. A covered person may appeal a claim denial pursuant to 34 chapter 514J. 35 -7- HF 2488.3860.S (1) 90 7/ 9

9. a. A covered person shall have access to a program that 1 directly rewards the covered person with a savings incentive 2 for medically necessary covered health care services received 3 from health care providers that offer a discounted cash price 4 below the average allowed amount. Annually at enrollment or 5 renewal, a health carrier shall provide notice to covered 6 persons via the health carrier’s health benefit plan materials 7 and the health carrier’s internet site of the savings incentive 8 program and how the savings incentive program works. If a 9 covered person exceeds the covered person’s annual deductible, 10 the covered person’s health benefit plan shall notify the 11 covered person of the savings incentive program and how the 12 savings incentive program works. 13 b. A covered person’s savings incentive for a specific 14 health care service shall be calculated as the difference 15 between the discounted cash price and the average allowed 16 amount. A savings incentive shall be divided equally between 17 the covered person and the covered person’s health benefit 18 plan, and may include a cash payment to the covered person. If 19 a third party helps facilitate a covered person in utilizing 20 a discounted cash price that saves money for the covered 21 person, the covered person may share a portion of their savings 22 incentive with the third party. 23 c. Savings incentives under this subsection shall not be 24 an administrative expense of the health benefit plan for rate 25 development or rate filing purposes. 26 10. This chapter shall not be construed to prohibit a health 27 care provider from billing a covered person, a covered person’s 28 guarantor, or a third-party payor including a health insurer, 29 for health care services provided to a covered person; or to 30 require a health care provider to refund any payment made to 31 the health care provider for a health care service provided to 32 a covered person. 33 11. If a provision of this chapter or its application to 34 any person or circumstance is held invalid, the invalidity does 35 -8- HF 2488.3860.S (1) 90 8/ 9

not affect other provisions or applications of this chapter 1 which can be given effect without the invalid provision or 2 application. 3 Sec. ___. SAVINGS INCENTIVE PROGRAM AND DEDUCTIBLE CREDIT 4 PROGRAM FOR STATE EMPLOYEES. 5 1. Before August 1, 2025, the department of administrative 6 services shall conduct an analysis of the cost-effectiveness of 7 offering a savings incentive program and deductible credit for 8 state employees and retirees. 9 2. On or before September 1, 2025, the department of 10 administrative services shall submit a report to the general 11 assembly that contains an explanation as to the decision to 12 implement, or not implement, a savings incentive program or 13 deductible credit program. 14 3. Any savings incentive program or deductible credit found 15 to be cost-effective shall be implemented for the 2026 state 16 employee health insurance open enrollment period. > 17 3. Title page, line 2, by striking < organizations > and 18 inserting < organizations, and certain cost controls for health 19 care services > 20 4. By renumbering as necessary. 21 -9- HF 2488.3860.S (1) 90 9/ 9 #3.