House
File
2488
S-5063
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.
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#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
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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.
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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
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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
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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
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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.
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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
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2488.3699
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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
______________________________
COMMITTEE
ON
HEALTH
AND
HUMAN
SERVICES
JEFF
EDLER,
CHAIRPERSON
-9-
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2488.3699
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90
nls/ko
9/
9
#3.
#4.