S.F. _____ Section 1. Section 507B.4, subsection 3, Code 2025, is 1 amended by adding the following new paragraph: 2 NEW PARAGRAPH . v. Improper denial of claims. A health 3 carrier improperly denying claims under chapter 514M. 4 Sec. 2. NEW SECTION . 514M.1 Short title. 5 This chapter shall be known and may be cited as “The 6 Patient’s Right to Save Act” . 7 Sec. 3. NEW SECTION . 514M.2 Definitions. 8 As used in this chapter, unless the context otherwise 9 requires: 10 1. “Average allowed amount” means the average of all 11 contractually agreed upon amounts paid by a health benefit 12 plan or a health carrier to a health care provider or other 13 entity participating in the health carrier’s network. The 14 average shall be calculated according to payments within a 15 reasonable amount of time not to exceed one calendar year. The 16 commissioner may approve methodologies for calculating the 17 average allowed amount that are based on any of the following: 18 a. A specific covered person’s health plan. 19 b. All health plans offered in the state by a specific 20 health carrier. 21 c. Geographic area. 22 2. “Cost-sharing” means any coverage limit, copayment, 23 coinsurance, deductible, or other out-of-pocket expense 24 obligation imposed on a covered person by a policy, contract, 25 or plan providing for third-party payment or prepayment of 26 health or medical expenses. 27 3. “Covered benefits” or “benefits” means health care 28 services that a covered person is entitled to under the terms 29 of a health benefit plan. 30 4. “Covered person” means a policyholder, subscriber, 31 enrollee, or other individual participating in a health benefit 32 plan. 33 5. “Discounted cash price” means the price an individual 34 pays for a specific health care service if the individual pays 35 -1- LSB 1498XC (5) 91 nls/ko 1/ 12

S.F. _____ for the health care service with cash or a cash equivalent. 1 6. “Health benefit plan” means a policy, contract, 2 certificate, or agreement offered or issued by a health carrier 3 to provide, deliver, arrange for, pay for, or reimburse any of 4 the costs of health care services. 5 7. “Health care provider” means a physician or other 6 health care practitioner licensed, accredited, registered, or 7 certified to perform specified health care services consistent 8 with state law, an institution providing health care services, 9 a health care setting, including but not limited to a hospital 10 or other licensed inpatient center, an ambulatory surgical 11 or treatment center, a skilled nursing center, a residential 12 treatment center, a diagnostic, laboratory, and imaging center, 13 or a rehabilitation or other therapeutic health setting. 14 8. “Health care services” means services for the diagnosis, 15 prevention, treatment, cure, or relief of a health condition, 16 illness, injury, or disease. 17 9. a. “Health carrier” means an entity subject to the 18 insurance laws and regulations of this state, or subject 19 to the jurisdiction of the commissioner, including an 20 insurance company offering sickness and accident plans, a 21 health maintenance organization, a nonprofit health service 22 corporation, a plan established pursuant to chapter 509A 23 for public employees, or any other entity providing a plan 24 of health insurance, health care benefits, or health care 25 services. 26 b. For purposes of this chapter, “health carrier” does not 27 include an entity providing any of the following: 28 (1) Coverage for accident-only, or disability income 29 insurance. 30 (2) Coverage issued as a supplement to liability insurance. 31 (3) Liability insurance, including general liability 32 insurance and automobile liability insurance. 33 (4) Workers’ compensation or similar insurance. 34 (5) Automobile medical-payment insurance. 35 -2- LSB 1498XC (5) 91 nls/ko 2/ 12

S.F. _____ (6) Credit-only insurance. 1 (7) Coverage for on-site medical clinic care. 2 (8) Other similar insurance coverage, specified in 3 federal regulations, under which benefits for medical care 4 are secondary or incidental to other insurance coverage or 5 benefits. 6 c. For purposes of this chapter, “health carrier” does not 7 include an entity providing benefits under a separate policy 8 including any of the following: 9 (1) Limited scope dental or vision benefits. 10 (2) Benefits for long-term care, nursing home care, home 11 health care, or community-based care. 12 (3) Any other similar limited benefits as provided by the 13 commissioner by rule. 14 d. For purposes of this chapter, “health carrier” does not 15 include an entity providing benefits offered as independent 16 noncoordinated benefits including any of the following: 17 (1) Coverage only for a specified disease or illness. 18 (2) A hospital indemnity or other fixed indemnity 19 insurance. 20 e. For purposes of this chapter, “health carrier” does 21 not include an entity providing a Medicare supplemental 22 health insurance policy as defined under section 1882(g)(1) 23 of the federal Social Security Act, coverage supplemental to 24 the coverage provided under 10 U.S.C. ch. 55, and similar 25 supplemental coverage provided to coverage under group health 26 insurance coverage. 27 10. “Pharmacist” means the same as defined in section 28 155A.3. 29 11. “Pharmacy” means the same as defined in section 155A.3. 30 Sec. 4. NEW SECTION . 514M.3 Health care services —— cost 31 controls. 32 1. a. All health care providers shall establish and 33 disclose the discounted cash price the health care provider 34 will accept for specific health care services. The disclosure 35 -3- LSB 1498XC (5) 91 nls/ko 3/ 12

S.F. _____ shall specify if the discounted cash price varies due to 1 different circumstances, including but not limited to the 2 day or time a health care service is provided, the office or 3 location at which the health care service is provided, how 4 quickly an individual pays the discounted cash price for a 5 health care service the individual received, the income level 6 of the individual who received the health care service, or 7 the ancillary services or amenities provided to an individual 8 at the same time the health care service is provided. The 9 discounted cash price shall be available to all covered persons 10 and to all uninsured individuals. A health care provider may 11 satisfy the requirements of this paragraph by complying with 12 the centers for Medicare and Medicaid services of the United 13 States department of health and human services hospital price 14 transparency regulations in 45 C.F.R. pt. 180. 15 b. A health care provider shall post all discounted cash 16 prices on the health care provider’s internet site in a 17 manner that is easily accessible to the public. A health care 18 provider shall update any change in a discounted cash price 19 within ten calendar days of the change, and shall review each 20 discounted cash price at least annually. 21 c. (1) Prior to the provision of a scheduled health care 22 service, a health care provider shall inform all covered 23 persons and uninsured individuals of the right of the covered 24 person or uninsured individual to pay for a health care service 25 via the discounted cash price. The notice may be provided 26 electronically, verbally, in writing, or posted at the physical 27 location of the health care provider. 28 (2) Prior to the provision of a scheduled health care 29 service, a health care provider shall inform a covered person 30 that the covered person may qualify for a deductible credit 31 if the covered person pays the discounted cash price for the 32 health care service and if the discounted cash price is below 33 the average allowed amount paid by the health carrier to 34 network providers for a comparable health care service. The 35 -4- LSB 1498XC (5) 91 nls/ko 4/ 12

S.F. _____ notice may be provided electronically, verbally, in writing, or 1 posted at the physical location of the health care provider. 2 d. A health care provider shall not enter into a contract 3 that prohibits the health care provider from offering a 4 discounted cash price below the contracted rates the health 5 care provider has with a health carrier, or that prohibits the 6 health care provider from disclosing the health care provider’s 7 discounted cash price under paragraph “b” . 8 e. A health carrier shall not enter into a contract with a 9 health care provider that prohibits the health care provider 10 from offering a discounted cash price below the contracted 11 rates the health care provider has with a health carrier, or 12 that prohibits the health care provider from disclosing the 13 health care provider’s discounted cash price under paragraph 14 “b” . 15 f. A covered person’s out-of-pocket pricing for each 16 prescription drug on a health carrier’s formulary shall be 17 available to a pharmacist via an easily accessible and secure 18 internet site hosted by the health carrier at the point the 19 pharmacist fills a prescription drug to the covered person. 20 g. A health care provider shall provide an individual with 21 an itemized list of all health care services provided to the 22 individual, a statement that the individual paid out-of-pocket 23 for the health care services, and a statement that the health 24 care provider will not make a claim against a health carrier 25 for payment for the health care services provided to the 26 individual if the individual is a covered person. 27 2. Each health benefit plan shall disclose to the health 28 benefit plan’s covered persons the average allowed amount for 29 each health care service that is covered under the covered 30 person’s health benefit plan. If a health benefit plan fails 31 to disclose the average allowed amount for a health care 32 service, a covered person may substitute a benchmark selected 33 by the commissioner. 34 3. A covered person who elects to receive a covered health 35 -5- LSB 1498XC (5) 91 nls/ko 5/ 12

S.F. _____ care service at a discounted cash price that is below the 1 average allowed amount shall receive credit toward the covered 2 person’s in-network cost-sharing as specified in the covered 3 person’s health benefit plan, as if the health care service is 4 provided by an in-network health care provider. 5 4. A health benefit plan shall not discriminate in the 6 form of payment for any covered in-network health care service 7 solely on the basis that the covered person was referred for 8 the health care service by an out-of-network health care 9 provider. 10 5. a. If a covered person elects to pay cash price for 11 a generic-brand covered prescription drug that results in a 12 lower cost than the average allowed amount for the name-brand 13 covered prescription drug under the covered person’s health 14 benefit plan, excluding any drug manufacturer’s rebate or 15 other discount from the average allowed amount, the health 16 benefit plan shall apply any payments made by the covered 17 person for the generic-brand covered prescription drug 18 to the covered person’s cost-sharing as specified in the 19 covered person’s health benefit plan as if the covered person 20 purchased the generic-brand prescription drug from a network 21 pharmacy using the covered person’s health benefit plan. The 22 health benefit plan shall credit half the difference in the 23 cash price for the generic-brand covered prescription drug 24 and the average allowed amount for the name-brand covered 25 prescription drug, excluding any drug manufacturer’s rebate 26 or other discount from the average allowed amount, toward 27 the covered person’s cost-sharing for health care services 28 that are covered or that are considered formulary under the 29 covered person’s health benefit plan. The health benefit 30 plan may credit half the difference in the cash price for 31 the generic-brand covered prescription drug and the average 32 allowed amount for the name-brand covered prescription drug, 33 excluding any drug manufacturer’s rebate or other discount 34 from the average allowed amount, toward the covered person’s 35 -6- LSB 1498XC (5) 91 nls/ko 6/ 12

S.F. _____ cost-sharing for health care services that are not covered 1 or that are considered nonformulary under the covered 2 person’s health benefit plan. This paragraph shall not be 3 construed to restrict a health benefit plan from requiring a 4 preauthorization or other precertification normally required by 5 the health benefit plan. 6 b. A health benefit plan shall provide a downloadable or 7 interactive online form for a covered person to submit proof of 8 payment under paragraph “a” , and shall annually inform covered 9 persons of their options under this subsection. 10 6. Annually at enrollment or renewal, a health carrier shall 11 provide notice to covered persons via the health carrier’s 12 health benefit plan materials and the health carrier’s internet 13 site of the option, and the process, to receive a covered 14 health care service at a discounted cash price. 15 7. If a covered person pays a discounted cash price that is 16 above the average allowed amount, the health benefit plan shall 17 credit the covered person’s cost-sharing an amount equal to 18 the lesser of the discounted cash price or the average allowed 19 amount. 20 8. a. If a health carrier denies a claim submitted by a 21 covered person pursuant to this chapter, the health carrier 22 shall notify the commissioner and provide evidence to support 23 the denial to the covered person and to the commissioner. 24 b. A covered person may appeal a claim denial pursuant to 25 chapter 514J. 26 9. a. A covered person shall have access to a program that 27 directly rewards the covered person with a savings incentive 28 for medically necessary covered health care services received 29 from health care providers that offer a discounted cash price 30 below the average allowed amount. Annually at enrollment or 31 renewal, a health carrier shall provide notice to covered 32 persons via the health carrier’s health benefit plan materials 33 and the health carrier’s internet site of the savings incentive 34 program and how the savings incentive program works. If a 35 -7- LSB 1498XC (5) 91 nls/ko 7/ 12

S.F. _____ covered person exceeds the covered person’s annual deductible, 1 the covered person’s health benefit plan shall notify the 2 covered person of the savings incentive program and how the 3 savings incentive program works. 4 b. A covered person’s savings incentive for a specific 5 health care service shall be calculated as the difference 6 between the discounted cash price and the average allowed 7 amount. A savings incentive shall be divided equally between 8 the covered person and the covered person’s health benefit 9 plan, and may include a cash payment to the covered person. If 10 a third party helps facilitate a covered person in utilizing 11 a discounted cash price that saves money for the covered 12 person, the covered person may share a portion of their savings 13 incentive with the third party. 14 c. Savings incentives under this subsection shall not be 15 an administrative expense of the health benefit plan for rate 16 development or rate filing purposes. 17 10. This chapter shall not be construed to prohibit a health 18 care provider from billing a covered person, a covered person’s 19 guarantor, or a third-party payor including a health insurer, 20 for health care services provided to a covered person; or to 21 require a health care provider to refund any payment made to 22 the health care provider for a health care service provided to 23 a covered person. 24 11. If a provision of this chapter or its application to 25 any person or circumstance is held invalid, the invalidity does 26 not affect other provisions or applications of this chapter 27 which can be given effect without the invalid provision or 28 application. 29 Sec. 5. SAVINGS INCENTIVE PROGRAM AND DEDUCTIBLE CREDIT 30 PROGRAM FOR STATE EMPLOYEES. 31 1. Before August 1, 2026, the department of administrative 32 services shall conduct an analysis of the cost-effectiveness of 33 offering a savings incentive program and deductible credit for 34 state employees and retirees. 35 -8- LSB 1498XC (5) 91 nls/ko 8/ 12

S.F. _____ 2. On or before September 1, 2026, the department of 1 administrative services shall submit a report to the general 2 assembly that contains an explanation as to the decision to 3 implement, or not implement, a savings incentive program or 4 deductible credit program. 5 3. Any savings incentive program or deductible credit found 6 to be cost-effective shall be implemented for the 2027 state 7 employee health insurance open enrollment period. 8 EXPLANATION 9 The inclusion of this explanation does not constitute agreement with 10 the explanation’s substance by the members of the general assembly. 11 This bill relates to certain cost controls for health care 12 services and may be cited as “The Patient’s Right to Save Act”. 13 Under the bill, all health care providers (providers) are 14 required to establish and disclose the discounted cash price 15 (cash price) the provider will accept for specific health care 16 services (services). “Discounted cash price” is defined in the 17 bill as the price an individual pays for a specific service 18 if the individual pays with cash or a cash equivalent. The 19 cash price shall be available to all covered persons (persons) 20 and to all uninsured individuals. A provider may satisfy the 21 requirements of the bill by complying with the United States 22 centers for medicare and medicaid services hospital price 23 transparency regulations in 45 C.F.R. pt. 180. A provider 24 shall post the cash prices on the provider’s internet site, 25 update any change in a cash price within 10 days of the change, 26 and review each cash price at least annually. 27 Prior to the provision of a scheduled health care service, 28 persons and uninsured individuals shall be informed of their 29 right to pay for the service via the cash price. A person 30 shall also be advised that they qualify for a deductible credit 31 if they have not exceeded their deductible to date, and the 32 criteria detailed in the bill is satisfied. 33 A provider shall not enter into a contract that prevents 34 the provider from offering a cash price below the contracted 35 -9- LSB 1498XC (5) 91 nls/ko 9/ 12

S.F. _____ rates the provider has with a health carrier (carrier), or that 1 prevents the provider from disclosing the provider’s cash price 2 to persons. 3 A person’s out-of-pocket pricing for each drug on a 4 carrier’s formulary shall be available to a pharmacist via 5 an easily accessible and secure internet site hosted by the 6 carrier at the point the pharmacist fills a prescription drug 7 to the person. 8 A provider shall provide an individual with an itemized list 9 of all services provided to the individual, a statement that 10 the individual paid out-of-pocket for the services, and if the 11 individual is a covered person, a statement that the provider 12 will not make a claim against the person’s carrier for payment 13 for the services provided. 14 Each plan shall disclose to the plan’s covered persons the 15 average allowed amount for each service that is covered under 16 the person’s plan. If a plan fails to disclose each average 17 allowed amount, a person may substitute a benchmark selected 18 by the commissioner of insurance (commissioner). A person who 19 elects to receive service at a cash price that is below the 20 average allowed amount shall receive credit toward the person’s 21 cost-sharing as if the service had been provided by a network 22 provider. “Average allowed amount” is defined in the bill. 23 A plan shall not discriminate in the form of payment for any 24 in-network covered service solely on the basis that the person 25 was referred for the service by an out-of-network provider. If 26 a person elects to pay cash price for a generic-brand drug that 27 results in a lower cost than the average allowed amount for the 28 name-brand drug under the person’s plan, the plan shall apply 29 any payments made by the person for the generic-brand drug as 30 detailed in the bill. A plan is required to provide an online 31 form for the purpose of a person submitting proof of payment. 32 Annually at enrollment or renewal, a carrier shall provide 33 notice to persons via the carrier’s health plan materials and 34 on the carrier’s internet site of the option and the process 35 -10- LSB 1498XC (5) 91 nls/ko 10/ 12

S.F. _____ to receive a covered service at a discounted cash price. If a 1 person pays a discounted cash price that is above the average 2 allowed amount, the plan shall give the person credit toward 3 the person’s cost-sharing in an amount equal to the cash price. 4 If a carrier denies a claim submitted by a person pursuant 5 to the bill, the carrier shall notify the commissioner and 6 provide evidence to support the denial to the person and the 7 commissioner. A person may appeal a denial of a claim as 8 detailed in the bill. 9 A person shall have access to a program that rewards the 10 person with a savings incentive for medically necessary 11 services received from providers that offer a cash price below 12 the average allowed amount. Annually at enrollment or renewal, 13 a carrier shall provide notice to persons via the carrier’s 14 internet site of the savings incentive program and how the 15 savings incentive program works. If a person exceeds the 16 person’s annual deductible, the person’s plan shall notify the 17 person of the savings incentive program. A person’s savings 18 incentives for a service shall be calculated as the difference 19 between the cash price and the average allowed amount. A 20 savings incentive shall be divided equally between the person 21 and the person’s plan, and may include a cash payment to the 22 person and a third party as described in the bill. 23 The bill shall not be construed to prohibit a provider from 24 billing a person, a person’s guarantor, or a third-party payor, 25 including a health insurer, for a service provided to the 26 person, or to require a provider to refund any payment made to 27 the provider for a service provided to the person. 28 If a provision of the bill or its application to any person 29 or circumstance is held invalid, the invalidity does not affect 30 other provisions or applications of the bill which can be given 31 effect without the invalid provision or application. 32 The bill directs the department of administrative services 33 (DAS) to conduct an analysis of the cost-effectiveness of 34 offering a savings incentive program and deductible credit for 35 -11- LSB 1498XC (5) 91 nls/ko 11/ 12

S.F. _____ state employees and retirees. DAS shall submit a report to the 1 general assembly on or before September 1, 2026, containing 2 an explanation as to the decisions to implement, or not to 3 implement, a savings incentive program or deductible credit 4 program. Any savings incentive program or deductible credit 5 program found to be cost-effective shall be implemented for the 6 2027 state employee health insurance open enrollment period. 7 -12- LSB 1498XC (5) 91 nls/ko 12/ 12