Senate File 431 - Introduced
SENATE FILE 431
BY BOUSSELOT
A BILL FOR
1 An Act relating to certain cost controls for health care
2 services, and including penalties.
3 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
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1 Section 1. Section 507B.4, subsection 3, Code 2023, is
2 amended by adding the following new paragraph:
3 NEW PARAGRAPH. u. Improper denial of claims. A health
4 carrier improperly denying claims under chapter 514M.1.
5 Sec. 2. NEW SECTION. 514M.1 Short title.
6 This chapter shall be known and may be cited as “The
7 Patient’s Right to Save Act”.
8 Sec. 3. NEW SECTION. 514M.2 Definitions.
9 As used in this chapter, unless the context otherwise
10 requires:
11 1. “Collection action” means any of the following actions
12 taken with respect to a debt for health care services purchased
13 from, or provided to a covered person by, a health care
14 provider on a date on which the health care provider was not in
15 material compliance with this chapter:
16 a. Attempting to collect a debt from a covered person or
17 a covered person’s guarantor by referring the debt, directly
18 or indirectly, to a debt collector, a collection agency, or
19 other third-party retained by or on behalf of the health care
20 provider.
21 b. Suing a covered person or a covered person’s guarantor,
22 or enforcing an arbitration or mediation clause in a health
23 care provider’s contract, agreement, statement, or bill.
24 c. Directly or indirectly causing a report to be made to a
25 consumer reporting agency.
26 2. “Collection agency” means a person that regularly
27 collects or attempts to collect, directly or indirectly,
28 debts owed, due, or asserted to be owed or due; that takes
29 assignment of debts for collection purposes; or that directly
30 or indirectly solicits for collection debts owed, due, or
31 asserted to be owed or due.
32 3. “Consumer reporting agency” means a person that for
33 monetary fees, dues, or on a cooperative nonprofit basis,
34 regularly engages in assembling or evaluating consumer credit
35 information, or other consumer information, for the purpose of
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1 providing consumer reports to third parties, and that uses any
2 means or facility of interstate commerce for the purpose of
3 preparing or furnishing consumer reports. “Consumer reporting
4 agency” does not include any person that only provides check
5 verification or check guarantee services.
6 4. “Cost-sharing” means any coverage limit, copayment,
7 coinsurance, deductible, or other out-of-pocket expense
8 obligation imposed on a covered person by a policy, contract,
9 or plan providing for third-party payment or prepayment of
10 health or medical expenses.
11 5. “Covered person” means the same as defined in section
12 514J.102.
13 6. “Debt” means an obligation or alleged obligation of a
14 consumer to pay money arising out of a transaction, whether or
15 not the obligation has been reduced to judgment. “Debt” does
16 not include a consumer debt incurred for business, investment,
17 commercial, or agricultural purposes, or a debt incurred by a
18 business.
19 7. “Debt collector” means a person employed or engaged by a
20 collection agency to perform debt collection.
21 8. “Deidentified minimum negotiated charge” means the lowest
22 charge for a specific health care service that a health care
23 provider has negotiated with a health carrier.
24 9. “Discounted cash price” means the price an individual
25 pays for a specific health care service if the individual pays
26 for the health care service with cash or a cash equivalent.
27 10. “Health benefit plan” means the same as defined in
28 section 514J.102.
29 11. “Health care provider” means a physician or other
30 health care practitioner licensed, accredited, registered, or
31 certified to perform specified health care services consistent
32 with state law, an institution providing health care services,
33 a health care setting, including but not limited to a hospital
34 or other licensed inpatient center, an ambulatory surgical
35 or treatment center, a skilled nursing center, a residential
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1 treatment center, a diagnostic, laboratory and imaging center,
2 or a rehabilitation or other therapeutic health setting.
3 12. “Health care services” means the same as defined in
4 section 514J.102.
5 13. “Health carrier” means the same as defined in section
6 514J.102.
7 14. “Pharmacist” means the same as defined in section
8 155A.3.
9 15. “Pharmacy” means the same as defined in section 155A.3.
10 Sec. 4. NEW SECTION. 514M.3 Health care services —— cost
11 controls.
12 1. a. All health care providers shall establish and
13 disclose the discounted cash price the health care provider
14 will accept for specific health care services. The disclosure
15 shall specify if the discounted cash price varies due to
16 different circumstances, including but not limited to the
17 day or time a health care service is provided, the office or
18 location at which the health care service is provided, how
19 quickly an individual pays the discounted cash price for a
20 health care service the individual received, the income level
21 of the individual who received the health care service, or
22 the ancillary services or amenities provided to an individual
23 at the same time the health care service is provided. The
24 discounted cash price shall be available to all covered persons
25 and to all uninsured individuals.
26 b. A health carrier shall post all discounted cash prices
27 via a secure internet site that is easily accessible to all
28 covered persons. A health carrier shall update any change in a
29 discounted cash price within five calendar days of the change,
30 and shall review each discounted cash price at least annually.
31 c. (1) During the appointment scheduling process, and any
32 intake process prior to the provision of a health care service,
33 covered persons and uninsured individuals shall be informed
34 of their right to pay for the health care service via the
35 discounted cash price.
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1 (2) During the appointment scheduling process, and any
2 intake process prior to the provision of a health care service,
3 a covered person shall be advised that they qualify for a
4 deductible credit if they have not exceeded their deductible to
5 date, and all of the following are true:
6 (a) The covered person pays the discounted cash price for
7 the health care service.
8 (b) The discounted cash price is below the deidentified
9 minimum negotiated charge for the specific health care service
10 that the covered person will receive.
11 d. A health carrier shall not enter into a contract that
12 prevents the health carrier from offering a discounted cash
13 price below the contracted rates the health carrier has with
14 other commercial or public payors, or that prevents the health
15 carrier from disclosing the health carrier’s discounted cash
16 price under paragraph “b”.
17 e. A covered person’s out-of-pocket pricing for each
18 prescription drug on a health carrier’s formulary shall be
19 available to a health care provider via an easily accessible
20 and secure internet site hosted by the health carrier at the
21 point the health care provider prescribes prescription drugs
22 to the covered person.
23 2. Each health benefit plan shall disclose to the health
24 benefit plan’s covered persons the deidentified minimum
25 negotiated charge for each health care service that is covered
26 under the covered person’s health benefit plan. If a health
27 benefit plan fails to disclose each deidentified minimum
28 negotiated charge, a covered person may substitute a benchmark
29 selected by the commissioner for the deidentified minimum
30 negotiated charge.
31 3. A covered person who elects to receive a covered health
32 care service at a discounted cash price that is below the
33 deidentified minimum negotiated charge shall receive credit
34 toward the covered person’s cost-sharing as specified in the
35 covered person’s health benefit plan, as if the health care
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1 service is provided by an in-network health care provider.
2 4. A health benefit plan shall not discriminate in the
3 form of payment for any covered in-network health care service
4 solely on the basis that the covered person was referred for
5 the health care service by an out-of-network health care
6 provider.
7 5. a. If a covered person elects to use a pharmacy discount
8 program, a drug manufacturer’s rebate, or other discount or
9 rebate program that results in a lower cost for a covered
10 prescription drug than if the covered person uses their health
11 benefit plan, the health benefit plan shall apply any payments
12 made by the covered person for the covered prescription drug to
13 the covered person’s cost-sharing as specified in the covered
14 person’s health benefit plan as if the covered person purchased
15 the prescription drug from a network pharmacy using the covered
16 person’s health benefit plan. The health benefit plan shall
17 credit the value of the rebate or other discount toward the
18 covered person’s cost-sharing for health care services that
19 are covered or that are considered formulary under the covered
20 person’s health benefit plan. The health benefit plan may
21 credit the value of the rebate or other discount toward the
22 covered person’s cost-sharing for health care services that
23 are not covered or that are considered nonformulary under the
24 covered person’s health benefit plan. This paragraph shall not
25 be construed to restrict a health benefit plan from requiring a
26 preauthorization or other precertification normally required by
27 the health benefit plan.
28 b. A health benefit plan shall provide a downloadable or
29 interactive online form for a covered person to submit proof of
30 payment under paragraph “a”, and shall annually inform covered
31 persons of their options under this subsection.
32 6. Annually at enrollment or renewal, a health carrier shall
33 provide notice to covered persons via the health carrier’s
34 health benefit plan materials and the health carrier’s internet
35 site of the option, and the process, to receive a covered
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1 health care service at a discounted cash price below the
2 deidentified minimum negotiated charge.
3 7. If a covered person pays a discounted cash price that is
4 above the deidentified minimum negotiated charge, the health
5 benefit plan shall credit the covered person’s cost-sharing an
6 amount equal to the discounted cash price.
7 8. a. If a health carrier denies a claim submitted by a
8 covered person pursuant to this chapter, the health carrier
9 shall notify the commissioner and provide evidence to support
10 the denial to the covered person and to the commissioner.
11 b. A covered person may appeal a claim denial to the
12 commissioner within sixty calendar days of the denial. The
13 appeal shall be adjudicated within thirty calendar days of the
14 covered person’s request for an appeal. If the commissioner
15 determines that the health carrier improperly denied the
16 covered person’s claim, the health carrier shall pay the
17 covered person’s costs and attorney fees associated with the
18 appeal, shall accept the covered person’s claim, and shall
19 provide cash compensation to the covered person in an amount
20 equal to the amount of the claim.
21 c. If a health carrier denies twenty or more claims in
22 any one quarter, the commissioner shall have the authority to
23 investigate the denials. If the commissioner finds that a
24 health carrier has improperly denied claims under this chapter,
25 or committed an unfair or deceptive act or practice under
26 section 507B.4, subsection 3, paragraph “u”, the commissioner
27 may conduct a hearing under section 507B.6.
28 9. a. For costs that exceed a covered person’s deductible,
29 the covered person shall have access to a program that directly
30 rewards the covered person with a savings incentive for
31 medically necessary covered health care services received from
32 health care providers that offer a discounted cash price below
33 the deidentified minimum negotiated charge. If a covered
34 person exceeds the covered person’s annual deductible, the
35 covered person’s health benefit plan shall notify the covered
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1 person of the savings incentive program and how the savings
2 incentive program works.
3 b. A covered person’s savings incentive for a specific
4 health care service shall be calculated as the difference
5 between the discounted cash price and the deidentified minimum
6 negotiated charge. A savings incentive shall be divided
7 equally between the covered person and the covered person’s
8 health benefit plan, and may include a cash payment to the
9 covered person.
10 c. Savings incentives under this subsection shall not be
11 an administrative expense of the health benefit plan for rate
12 development or rate filing purposes.
13 10. a. A health care provider shall not initiate or pursue
14 a collection action against a covered person, or a covered
15 person’s guarantor, for a debt owed for a health care service
16 unless the health care provider is in material compliance with
17 this chapter on the date that the health care provider provided
18 the health care service to the covered person.
19 b. If a health care provider initiates or pursues a
20 collection action in violation of paragraph “a”, the covered
21 person or the covered person’s guarantor may file for a
22 declaratory judgment with a court of competent jurisdiction
23 and the health care provider shall not continue the collection
24 action against the covered person, or the covered person’s
25 guarantor, while the lawsuit is pending. If the court finds in
26 favor of the covered person, or the covered person’s guarantor,
27 the court shall order the health care provider to do all of the
28 following:
29 (1) Refund a payor any amount the payor paid for the debt
30 that is the subject of the lawsuit.
31 (2) Pay a penalty to the covered person, or the covered
32 person’s guarantor, in an amount equal to the total amount of
33 the debt that is the subject of the lawsuit.
34 (3) Dismiss with prejudice, or cause to be dismissed with
35 prejudice, any court action related to the collection action
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1 or the lawsuit.
2 (4) Pay any attorney fees and costs incurred by the covered
3 person, or the covered person’s guarantor, related to the
4 collection action or the lawsuit.
5 (5) Remove or cause to be removed from the covered person’s
6 or the covered person’s guarantor’s credit report any report
7 made to a consumer reporting agency related to the debt that
8 is the subject of the lawsuit.
9 11. Provided that a health care provider does not initiate
10 or pursue a collection action in violation of this chapter,
11 this chapter shall not be construed to prohibit a health care
12 provider from billing a covered person, a covered person’s
13 guarantor, or a third-party payor including a health insurer,
14 for health care services provided to a covered person; or to
15 require a health care provider to refund any payment made to
16 the health care provider for a health care service provided to
17 a covered person.
18 12. If a provision of this chapter or its application to
19 any person or circumstance is held invalid, the invalidity does
20 not affect other provisions or applications of this chapter
21 which can be given effect without the invalid provision or
22 application.
23 EXPLANATION
24 The inclusion of this explanation does not constitute agreement with
25 the explanation’s substance by the members of the general assembly.
26 This bill relates to certain cost controls for health care
27 services and may be cited as “The Patient’s Right to Save Act”.
28 Under the bill, all health care providers (providers) are
29 required to establish and disclose the discounted cash price
30 (cash pric